Item C35 BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: September 17, 2013 Division: Employee Services
Bulk Item: Yes X No _ Department: Employee Benefits
Staff Contact Person/Phone #: Maria Gonzalez Ext. 4448
AGENDA ITEM WORDING: Approval of revisions to the Benefit Booklet (Plan Document) for
Covered Plan Participants of the Group Health Insurance Plan
ITEM BACKGROUND: The revisions clarify coverage for participants in regards to their benefits
and how they are being administered. Other revisions are in compliance with the Patient Protection
and Affordable Care Act (PPACA). There is no substantive dollar impact for the changes being
recommended. The changes mostly clarify language regarding benefits for covered plan participants.
PREVIOUS RELEVANT BOCC ACTION: On November 20, 2012, the BOCC approved the
current Plan Document with Blue Cross Blue Shield of Florida.
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATIONS: Approval
TOTAL COST: N/A INDIRECT COST: BUDGETED: Yes _No
DIFFERENTIAL OF LOCAL PREFERENCE:
Internal Service Fund
COST TO COUNTY: N/A SOURCE OF FUNDS: Primarily Ad Valorem
REVENUE PRODUCING: Yes No X AMOUNT PER MONTH Year
P
APPROVED BY: County Att_ OMB/Purcliasing Risk Managemeyd�
DOCUMENTATION: Included X Not Required
DISPOSITION: AGENDA ITEM#
Revised 7/09
Ad& BOARD OF COUNTY COMMISSIONERS
County of Monroe Mayor George ,Heatheeugent,r
District 2
Mayor Pro Tern,Heather Carruthers,District 3
The Florida Keys Danny L.Kolhage,District 1
David Rice,District 4
Sylvia J.Murphy,District 5
Office of the Employee Services Division Director
The Historic Gato Cigar Factory
1100 Simonton Street,Suite 268
Key West,FL 33040
(305)292-4458—Phone
(305)292-4564-Fax
TO: Mayor Neugent and Commissioners
FROM: Teresa Aguiar, Director
Employee Services
DATE: July 31, 2013
SUBJ: Group Health Plan Document—Revisions
This item requests approval to revise the Plan Document for covered plan participants. This is the sole
document used in determining the benefits of eligible covered persons of the County's Health Insurance
Plan.
The Plan is being revised as follows:
• Page 2-3 Newly Added Language clarifies coverage. There is no change in the benefit
Payment Guidelines for Autism Spectrum Disorder
The covered therapies provided in the treatment of Autism Spectrum Disorder outlined in paragraph three
above will be applied to the Outpatient Therapies Benefit Period maximum set forth in the Schedule of
Benefits. Autism Spectrum Disorder Services must be authorized in accordance with the BCBSF's
established criteria,before such Services are rendered. Services performed without authorization will be
denied. Authorization for coverage is not required when Covered Services are provided for the treatment of
an Emergency Medical Condition.
Exclusion:
Any Services for the treatment of Autism Spectrum Disorder other than as specifically identified as covered
in this section.
Note: In order to determine whether such Services are covered under this Benefit Booklet,we reserve the
right to request a formal written treatment plan signed by the treating Physician to include the diagnosis,the
proposed treatment type,the frequency with which the treatment plan will be updated, but no less than
every 6 months. This Benefit Booklet will only cover services to the extent included in the treating
physician's formal written treatment plan.
1 of 7
• Page 2-6 Newly added language regarding payment under the requirements of PPACA (Patient
Protection and Affordable Care Act)for Emergency Medical Services.
Emergency Services
Emergency Services for an Emergency Medical Condition are covered when rendered in-Network and Out-
of-Network without the need for any prior authorization determination by us.
When Emergency Services and care for an Emergency Medical Condition are rendered by an Out-of-
Network Provider,any Copayment and/or Coinsurance amount applicable to in-Network Providers for
Emergency Services will also apply to such Out-of-Network Provider.
Special Payment Rules for Non-Grandfathered Plans
The Patient Protection and Affordable Care Act(PPACA)requires that non-grandfathered health plans
apply a specific method for determining the allowed amount for Emergency Services rendered for an
Emergency Medical Condition by Providers who do not have a contract with us.
Payment for Emergency Services rendered by an Out-of-Network Provider that has not entered into an
agreement with BCBSF to provide access to a discount from the billed amount of that Provider will be the
greater of:
1. the amount equal to the median amount negotiated with all BCBSF In-Network Providers for the
same Services;
2. the Allowed Amount as defined in the Booklet;
3. the usual and customary Provider charges for similar Services in the community where the Services
were provided, or
4. what Medicare would have paid for the Services rendered.
In no event will Out-of-Network Providers be paid more than their charges for the Services rendered.
• Page 2-13 Language consolidated to incorporate adults and children rather than breaking them
out into two separate components. There are no substantive changes. `a'through `h'is a
requirement of PPA CA.
• Page 2-14 Exclusions—Language added to define the guidelines used by BCBSFL for
sterilization and contraceptive implants.
Preventative Adult Welln Health Services
Preventative adult wellness Services are covered for both adults and children based on prevailing
medical standards and recommendations which are explained further below. Some examples of
preventive health Services include,but are not limited to, periodic routine health exams,
immunizations and related preventive Services such as Prostate Specific Antigen(PSA),routine
mammograms and pan smears. In order to be covered, Services shall be provided in accordance
with prevailing medical standards consistent with: amour-plan For-par-poses of this L.o^��+,
an adult is 17 year-s or-elder-.
in ordeF to be eever-ed, SeFviees shall be provided in aeraer-danee with pf:e ailing fnediraal standards
2 of 7
1. Evidence-based items or Services that have in effect a rating of`A' or `B' in the current
recommendations of the U.S. Preventative Services Task Force established under the Public
Health Service Act;
2. Immunizations that have in effect a recommendation from the Advisory Committee on
immunization Practices of the Centers for Disease Control and Prevention established under the
Public Health Service Act with respect to the individual involved; and
3. with respect to women, such additional preventative care and screenings not described in
paragraph(4-)number one as provided for in comprehensive guidelines supported by the Health
Resources and Services Administration. Women's preventive coverage under this category
includes:
a. well-woman visits;
b. Screening for gestational diabetes;
c. Human papillomavirus testing;
d. Counseling for sexually transmitted infections;
e. Counseling and screening for human immune-deficient vy irus;
f. Contraceptive methods and counseling;
g_ Screening and counseling for interpersonal and domestic violence, and
h. Breastfeeding support supplies and counseling. Breastfeeding supplies are limited to one
manual breast pump per pregnancy.
Exclusion:
Routine vision and hearing examinations and screenings are not covered,except as required under
paragraph number one above. Sterilization Procedures covered under this section are limited to
tubal ligations only. Contraceptive implants are limited to Intrauterine devices(IUD)only,
including insertion and removal.
Preventative Child Mealth Supervision Sen4ees
hirthdaY afe
eevered.
1 id based items a Sefyiees that heave ' ff t 4i« f'A' 'B' the t
�pTlQpfipp-pQ�ITiCGI1TS"17r4GIl�GOSC'lRir'lliTtO'�77rGITOGt-CTTCTCIII�p�2 I i pI D III CIIG eC[rrGilHealth Sen4ee r-eeemmendations of the U.S. Preventive Seniees Task For-ee es4ablished under-the Public
f
7 z 4ions tha4 have i e ff et n admien -rem the Advise.-y Commit+°° e
involved;immuniza4ien Pr-aetiraes of the Centers fer-Disease Control and Wevenfien established unde
3. with r-espeet to f f and f
• Page 3-1 Language removed regarding adult wellness in compliance with PPACA.
3 of 7
• Page 3-4 Language removed in regards to the specific reference to Child and Adult in
compliance with PPA CA.
Immunizations except those covered under the Preventive Child Health gupem4sien Services or I eventive
Adult Wellness Ser-viees sategeFies category of the"What is Covered?" section.
• Page 5-2 Newly added language to address the Per Admission Deductible and Emergency Room
Visit Deductible. There is no change in the benefit.
4. Emergency Room Facility Copayment:
The emergency room facility Copayment applies regardless of the reason for the visit, is in addition to the
applicable Coinsurance amount,and applies to emergency room facility Services in or outside the state of
Florida. The emergency room facility Copayment must be satisfied by you for each visit. If you are
admitted to the Hospital as an inpatient at the time of the emergency room visit,the emergency room
facility Copayment will be waived, but you will still be responsible for the inpatient facility Copayment.
Hospital Per Admission Deductible
The Hospital Per Admission Deductible(PAD)must be satisfied by each Covered Plan Participant,for each
Hospital admission,before any payment will be made for any claim for inpatient Health Care Services. The
Hospital Per Admission Deductible applies regardless of the reason for the admission, is in addition to the
Deductible requirement, and applies to all Hospital admissions in or outside the state of Florida.
Emergency Room Per Visit Deductible
The Emergency Room Per Visit Deductible(PVD) is set for the in the Schedule of Benefits. The
Emergency Room Per Visit Deductible applies regardless of the reason for the visit, is in addition to the
Deductible,and applies to emergency room services in or outside the state of Florida. The Emergency
room Per Visit Deductible must be satisfied by each Covered Plan Participant for each visit. If the Covered
Plan Participant is admitted to the Hospital at the time of the emergency room visit,the Emergency Room
Per Visit Deductible will be waived.
• Page 5--3 Clarification of language of how Plan is set up and being administered There is no
change in benefit
Family out-of-pocket maximum
If your plan includes a family out-of-pocket maximum, once your family has reached the family—out-of
pocket maximum amount listed in the Schedule of Benefits,neither you nor your covered family members
will have any additional out-of-pocket responsibility for the remainder of that Benefit Period and we will
pay 100 percent of the Allowed Amount for Covered Services rendered during the remainder of that Benefit
Period. The maximum amount any one Covered Person in your family can contribute toward the family ou-
of-pocket maximum, if applicable, is the amount applied toward the individual out-of-pocket maximum.
Please see your Schedule of Benefits for more information.
Note: The-Dedestible, any applicable Copayments and Coinsurance amounts will accumulate toward the
out-of-pocket maximums. Any benefit penalty reductions, Deductible,PAD, PVD, non-covered charges or
any charges in excess of the allowed Amount will not accumulate toward the out-of-pocket maximums. If
4of7
the Group has purchased Prescription Drug coverage,any applicable Cost Share under the Prescription
Drug coverage,will not apply to the Deductible or the out-of-pocket maximums under this Booklet.
• Page 74 Clarification of language describing how payment are being made to the BlueCard
(out of State)Providers. No change in benefits.
BlueCard(Out-of-State)Program
the amount yeu pay for-Gever-ed Sef-viees is ealeaule4ed on the!owe
The negetiated priee theA the oft site Blue Cross and/er-Blue Shield Plan("Host Blue")passes e
OR a,this"fiegetieAed Providers Outside the Sme of FlorWa
withhelds,an),ether-eantingent payment a"angements and fien ralaims 4msaetiens with your-health rare
Pr-evider-ef with a specified gfeep of Providers. The negotiated pFiee f"ay alse be bbilled aahmges r-edaeed
Fefleet an aver-age expeeted savings with year-health eafe Pr-evider-er-with a speeified group of Pr-evide
The pr-iee that fellee4s — . gs may result in gmmer-var-iatiea(more er-less)ffem the aetual pr-ioe
paid than will the estimated pfiee. The negetiated pAraelAill alse be pr-espeefively!djusted in the fi4"
eeffeet fer-ever- or-under-estimation ef past priees. However-,the affieffflt)'OH pay*S refiSideFed a final
wise:
StffPdtes in a small nufobff ef states may r-equir-e the Hest Blue to use a basis for-ealetilating a raever-ed
individual's liability for-Cevefed Sef:N,iees that does fiet r-efleet the efftir-e savings malized, of:expeeted to be
realized,en a paAietilar-elaim er-te add a surehar-ge. Should afty state stattAes fnaffdate liability ealetilatieft
fnetheds that differ-ftem the usual 13IueQrd fnethed neted abeve in par-agf:aph ene of this seetien Or-Feqtfife
a suFehar-ge,we will then ealeaulate your-liability fer-any Govefed Sef-Aees ift aeeer-danee with the applieab4e
Out-of-Area Services
We have a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally
as"Inter-Plan Programs". Whenever you obtain Health Care Services outside of our service area,the
claims for these Services may be processed through one of these Inter-Plan Programs,which include the
BlueCard Program and may include negotiated national Account arrangements available between us and
other Blue Cross and Blue Shield Licensees.
Typically,when accessing care outside our service area,you will obtain care from health care Providers that
have a contractual agreement(i.e., are"participating providers")with the local Blue Cross and/or Blue
Shield Licensee in that other geographic area("Host Blue"). In some instances,you may obtain care from
non-participating health care Providers. Our payment practices in both instances are described below.
BlueCard Program
Under the BlueCard Program when you access Covered Services within the geographic area served by a
Host Blue we will remain responsible for fulfilling our contractual obligations. However,the Host Blue is
responsible for contracting with and generally handling all interactions with its participating health care
Providers.
5 of 7
Whenever you access Covered Services outside our service area and the claim is processed through the
B1ueCard Program,the amount you pay for Covered Services is calculated based on the lower of:
• The billed covered charges for your Covered Services;or
• The negotiated price that Host Blue makes available to us.
Often,this"negotiated price"will be a simple discount that reflects an actual price that the Host Blue pays
to your health care Provider. Sometimes, it is an estimated price that takes into account special
arrangements with your health care Provider or Provider group that may include types of settlements,
incentive payments, and/or other credits or charges. Occasionally, it be an average price, based on a
discount that results in expected average savings for similar types of health care Providers after taking into
account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward,also take into account adjustments to correct for
over-or underestimation of modifications of past pricing for the types of transaction modifications noted
above. However, such adjustments will not affect the price we use for your claim because they will not be
gpplied retroactively to claims already paid.
Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any
state laws mandate other liability calculation methods, including a surcharge,we would then calculate your
liability for any Covered Services according to applicable law.
Out-of-Network Providers Outside Our Service Area
Your Liability Calculation
When Covered Services are provided outside of our service area by non-participating health care Providers,
the payment will be based on the Allowed Amount as defined in the Benefit Booklet.
• Page 8-3 Language removed in regards to the prescription drug prior authorization
requirements. Envision handles the County's Prescription Drug Program. BCBSFL handles
only the medical pharmacy.
Out-of-Network Providers
1. in the ease of Preseription Drugs defieted with a speeial syfflbel in the Medioafien Guide as
denial of eover-age for-sueh Preseription Drug,ineluding any Se- Felated—to the
Freser-iption Drug or-its administrutio*.
FeF additional details oft how to ebtain. ' —�at4her-im4iefi,and for-a list of Weser-ipti
• Page 10-1 Language clarified from Covered Employee/Retiree to Participant. No change in
benefits.
Eligibility Requirements for Dependent(s)
6 of 7
An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible to
apply for coverage under this Booklet.
1. The Covered I leyee�Retir-ee's Plan Participant's spouse under a legally valid existing marriage
under Federal Law.
2. The Covered Efnpleyee4W s Plan Participant's natural, newborn, adopted, Foster,or step
child(ren)(or a child for who the Covered Employee has been court-appointed as legal guardian or
legal custodian)who has not reached the end of the Calendar Year in which he or she reaches age
26(or in the case of a Foster Child, is no longer eligible under the Foster Child Program),
regardless of the dependent child's student or marital status, financial dependency on the Covered
Employee,whether the dependent child resides with the Covered Employee, or whether the
dependent child is eligible for or enrolled in any other group health plan.
• Page 10-2 Handicapped Children—Language changed from the age of 30 to 26. This provides
more flexibility for Handicapped dependents because they now do not need to be students or
living in Florida between the ages of 26 and 30 to quay for coverage.
Handicapped Children
In the case of a handicapped dependent child, such child is eligible to continue coverage as a Covered
Dependent,beyond the age of 30 26, if the child is:
1. otherwise eligible for coverage under the Group Health Plan;
2. incapable of self-sustaining employment by reason of mental retardation or physical handicap; and
3. chiefly dependent upon the Covered Employee for support and maintenance provided that the
symptoms or causes of the child's handicap existed prior to the child's;e 26 1'birthday.
This eligibility shall terminate on the last day of the month in which the dependent child no longer meets
the requirements for extended eligibility as a handicapped child.
7of7
l
Revised
BlueOptions
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
BlueOptions
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
A Self-funded Group Health
�= Benefit Plan
For Customer Service
Assistance: (800) 664-5295
B0611—1/1/13
Divisions 001,C01,R01,R02,002
Table of Contents
Section 1: How to Use Your Benefit Booklet............................................................. 1-1
Section2: What Is Covered?.....................................................................................2-1
Section 3: What Is Not Covered?..............................................................................3-1
Section 4: Medical Necessity ....................................................................................4-1
Section 5: Understanding Your Share of Health Care Expenses..............................5-1
Section 6: Physicians, Hospitals and Other Provider Options...................................6-1
Section 7: BlueCarde(Out-of-State) Program...........................................................7-1
Section 8: Blueprint for Health Programs..................................................................8-1
Section 9: Pre-existing Conditions Exclusion Period.................................................9-1
Section 10: Eligibility for Coverage............................................................................ 10-1
Section 11: Enrollment and Effective Date of Coverage............................................ 11-1
Section 12: Termination of Coverage........................................................................ 12-1
Section 13: Continuing Coverage Under COBRA..................................................... 13-1
Section 14: Conversion Privilege...................................................................14-1
Section 15: Extension of Benefits..................................................................15-1
Section 16: The Effect of Medicare Coverage/ Medicare Secondary Payer
Provisions .............................................................................................. 16-1
Section 17: Duplication of Coverage Under Other Health Plans/Programs............... 17-1
Section18: Subrogation............................................................................................ 18-1
Section 19: Right of Reimbursement......................................................................... 19-1
Section 20: Claims Processing..................................................................................20-1
Section 21: Relationship Between the Parties...........................................................21-1
Section 22: General Provisions.................................................................................22-1
Section 23: Definitions...............................................................................................23-1
Table of Contents
Section 1 : How to Use Your Benefit Booklet
This is your Benefit Booklet("Booklet"). It be coordinated with other policies or plans;
describes your coverage, benefits, limitations and the Group Health Plan's subrogation
and exclusions for the self-funded Group Health rights and right of reimbursement.
Benefit Plan ("Group Health Plan" or"Group You will need to refer to the Schedule of
Plan")established and maintained by Monroe Benefits to determine how much you have to
County BOCC. pay for particular Health Care Services.
The sponsor of your Group Health Plan has
contracted with Blue Cross Blue Shield of When reading your Booklet, please
Florida, Inc. (BCBSF), under an Administrative remember that:
Services Only Agreement("ASO Agreement"), • you should read this Booklet in its entirety in
to provide certain third party administrative order to determine if a particular Health Care
services,including claims processing, customer
Service is covered.
service, and other services, and access to
certain of its Provider networks. BCBSF • the headings of sections contained in this
provides certain administrative services only and Booklet are for reference purposes only and
does not assume any financial risk or obligation shall not affect in any way the meaning or
with respect to Health Care Services rendered to interpretation of particular provisions.
Covered Persons or claims submitted for references to"you"or"your'throughout refer
processing under this Benefit Booklet for such to you as the Covered Plan Participant and to
Services.The payment of claims under the your Covered Dependents, unless expressly
Group Health Plan depends exclusively upon stated otherwise or unless, in the context in
the funding provided by Monroe County BOCC. which the term is used, it is clearly intended
You should read your Benefit Booklet carefully otherwise. Any references which refer solely
before you need Health Care Services. It to you as the Covered Plan Participant or
contains valuable information about: solely to your Covered Dependent(s)will be
noted as such.•
your BlueOptions benefits;
•• what is covered; references to"we", "us", and "our"throughout
refer to Blue Cross and Blue Shield of
• what is excluded or not covered; Florida, Inc. We may also refer to ourselves
• coverage and payment rules; as"BCBSF".
• Blueprint for Health Programs; if a word or phrase starts with a capital letter,
it is either the first word in a sentence, a
• how and when to file a claim; proper name,a title, or a defined term. If the
• how much, and under what circumstances, word or phrase has a special meaning, it will
payment will be made; either be defined in the Definitions section or
defined within the particular section where it
• what you will have to pay as your share; and is used.
• other important information including when
benefits may change; how and when
coverage stops; how to continue coverage if
you are no longer eligible; how benefits will
How to Use Your Benefit Booklet 1-1
Where do you find information on........
• what particular types of Health Care • how to add or remove a Dependent?
Services are covered? Read the"Enrollment and Effective Date of
Read the"What Is Covered?"and "What Is Coverage"section.
Not Covered?"sections. • what happens if you are covered under
• how much will be paid under your Group this Benefit Booklet and another health
Health Plan and how much do you have to plan?
pay? Read the"Duplication of Coverage Under
Read the"Understanding Your Share of Other Health Plans Programs'section.
Health Care Expenses'section along with the • what happens when your coverage ends?
Schedule of Benefits.
• how the amount you pay for Covered Read the"Termination of Coverage"section.
Services under the BlueCard (Out-of- • what the terms used throughout this
State) Program will be determined when Booklet mean?
you receive care outside the state of Read the"Definitions"section.
Florida?
Read the'BlueCard(Out-of-State) Program"
section.
Overview of How BlueOptions Works
Whenever you need care, you have a choice. If you visit an:
In-Network Provider Out-of-Network Provider
You receive In-Network benefits, the You receive the Out-of-Network level of
highest level of coverage available. benefits—you will share more of the cost of
your care.
You do not have to file a claim;the claim You may be required to submit a claim form.
will be filed by the In-Network Provider for
you.
The In-Network Provider'is responsible You should notify BCBSF of inpatient
for Admission Notification if you are admissions.
admitted to the Hospital.
"For Services rendered by an In-Network Provider located outside of Florida, you should
notify us of inpatient admissions.
How to Use Your Benefit Booklet 1-2
Section 2: What Is Covered.
Introduction Necessity coverage criteria then in effect,
except as specified in this section;
This section describes the Health Care Services
that are covered under this Benefit Booklet. All 4. in accordance with the benefit guidelines
benefits for Covered Services are subject to listed below;
your share of the cost and the benefit 5. rendered while your coverage is in force;
maximums listed on your Schedule of Benefits, and
the applicable Allowed Amount an limitations
Y PP � 6. not specifically or generally limited(e.g.,
and/or exclusions, as well as other provisions Pre-existingCondition exclusionary period)
rY P )
contained in this Booklet, and any or excluded under this Booklet.
Endorsement(s)in accordance with BCBSF's
Medical Necessity coverage criteria and benefit BCBSF or Monroe County BOCC will determine
guidelines then in effect. whether Services are Covered Services under
this Booklet after you have obtained the
Remember that exclusions and limitations also Services and a claim has been received for the
apply to your coverage. Exclusions and Services. In some circumstances BCBSF or
limitations that are specific to a type of Service Monroe County BOCC may determine whether
are included along with the benefit description in Services might be Covered Services under this
this section. Additional exclusions and Booklet before you are provided the Service.
limitations that may apply can be found in the For example, BCBSF or Monroe County BOCC
'What Is Not Covered?"section. More than one may determine whether a proposed transplant is
limitation or exclusion may apply to a specific a Covered Service under this Booklet before the
Service or a particular situation. transplant is provided. Neither BCBSF nor
Expenses for the Health Care Services listed in Monroe County BOCC are obligated to
this section will be covered under this Booklet determine, in advance, whether any Service not
only if the Services are: yet provided to you would be a Covered Service
unless we have specifically designated that a
1. within the Health Care Services categories Service is subject to a prior authorization
in the"What Is Covered?" section; requirement as described in the"Blueprint for
2. actually rendered(not just proposed or Health Programs"section. We are also not
recommended)by an appropriately licensed obligated to cover or pay for any Service that
health care Provider who is recognized for has not actually been rendered to you.
payment under this Benefit Booklet and for In determining whether Health Care Services
which an itemized statement or description are Covered Services under this Booklet, no
of the procedure or Service which was written or verbal representation by any
rendered is received, including any employee or agent of BCBSF or Monroe County
applicable procedure code, diagnosis code BOCC, or by any other person, shall waive or
and other information required in order to otherwise modify the terms of this Booklet and,
process a claim for the Service; therefore, neither you, nor any health care
3. Medically Necessary, as defined in this Provider or other person should rely on any such
Booklet and determined by BCBSF in written or verbal representation.
accordance with BCBSF's Medical
What Is Covered? 2-1
Our Benefit Guidelines number of tests performed by the Physician.
The Allowed Amount for allergy immunotherapy
In providing benefits for Covered Services,the treatment is based upon the type and number of
benefit guidelines listed below apply as well as doses.
any other applicable payment rules specific to
particular categories of Services: Ambulance Services
1. Payment for certain Health Care Services is Ambulance Services provided by a ground
included within the Allowed Amount for the vehicle may be covered provided it is necessary
primary procedure, and therefore no to transport you from:
additional amount is payable for any such 1. a Hospital which is unable to provide proper
Services. care to the nearest Hospital that can provide
2. Payment is based on the Allowed Amount proper care;
for the actual Service rendered(i.e., 2. a Hospital to your nearest home,or to a
payment is not based on the Allowed Skilled Nursing Facility; or
Amount for a Service which is more complex
than that actually rendered), and is not 3. the place a medical emergency occurs to
based on the method utilized to perform the the nearest Hospital that can provide proper
Service or the day of the week or the time of care.
day the procedure is performed. Expenses for Ambulance Services by boat,
3. Payment for a Service includes all airplane, or helicopter shall be limited to the
components of the Health Care Service Allowed Amount for a ground vehicle unless:
when the Service can be described by a 1. the pick-up point is inaccessible by ground
single procedure code, or when the Service vehicle;
is an essential or integral part of the
associated therapeutic/diagnostic Service 2. speed in excess of ground vehicle speed is
critical;or
rendered.
3. the travel distance involved in getting you to
Covered Services Categories the nearest Hospital that can provide proper
care is too far for medical safety, as
Accident Care determined by BCBSF or Monroe County
Health Care Services to treat an injury or illness BOCC.
resulting from an Accident not related to your job Please refer to your Schedule of Benefits for the
or employment are covered. per-day maximums for ground transportation
Exclusion: and air/water transportation.
Health Care Services to treat an injury or illness Ambulatory Surgical Centers
resulting from an Accident related to your job or
employment are excluded. Health Care Services rendered at an Ambulatory
Surgical Center are covered and include:
Allergy Testing and Treatments 1. use of operating and recovery rooms;
Testing and desensitization therapy(e.g., 2. respiratory,or inhalation therapy p• ry. PY(e.g.,
injections)and the cost of hyposensitization oxygen);
serum are covered. The Allowed Amount for
allergy testing is based upon the type and
What Is Covered? 2-2
3. drugs and medicines administered(except 1. well-baby and well-child screening for the
for take home drugs)at the Ambulatory presence of Autism Spectrum Disorder;
Surgical Center;
2. Applied Behavior Analysis,when rendered
4. intravenous solutions; by an individual certified pursuant to Section
5. dressings, including ordinary casts; 393.17 of the Florida Statutes or licensed
under Chapters 490 or 491 of the Florida
6. anesthetics and their administration; Statutes;and
7. administration of, including the cost of, 3. Physical Therapy by a Physical Therapist,
whole blood or blood products(except as Occupational Therapy by an Occupational
outlined in the Drugs exclusion of the"What Therapist, and Speech Therapy by a
Is Not Covered?"section);
Speech Therapist. Covered therapies
8. transfusion supplies and equipment; provided in the treatment of Autism
9. diagnostic Services, including radiology, Spectrum Disorder are covered even though
ultrasound, laboratory, pathology and they may be habilitative in nature(provided
approved machine testing(e.g., EKG); and to teach a function)and are not necessarily
limited to restoration of a function or skill that
10. chemotherapytreatment for proven has been lost.
malignant disease.
Payment Guidelines for Autism Spectrum
Anesthesia Administration Services Disorder
Administration of anesthesia by a Physician or The covered therapies provided in the treatment
Certified Registered Nurse Anesthetist("CRNA") of Autism Spectrum Disorder outlined in
may be covered. In those instances where the paragraph three above will be applied to the
CRNA is actively directed by a Physician other Outpatient Therapies Benefit Period maximum
than the Physician who performed the surgical set forth in the Schedule of Benefits.Autism
procedure, payment for Covered Services, if Spectrum Disorder Services must be authorized
any, will be made for both the CRNA and the in accordance with BCBSF's established criteria,
Physician Health Care Services at the lower before such Services are rendered. Services
directed-services Allowed Amount in accordance performed without authorization will be denied.
with BCBSF's payment program then in effect Authorization for coverage is not required when
for such Covered Services. Covered Services are provided for the treatment
of an Emergency Medical Condition.
Exclusion:
Exclusion:
Coverage does not include anesthesia Services
by an operating Physician, his or her partner or Any Services for the treatment of Autism
associate. Spectrum Disorder other than as specifically
identified as covered in this section.
Autism Spectrum Disorder Note: In order to determine whether such
Autism Spectrum Disorder Services provided to Autism Spectrum Disorder Services are covered
a Covered Dependent who is under the age of under this Benefit Booklet, we reserve the right
18, or if 18 years of age or older, is attending to request a formal written treatment plan signed
high school and was diagnosed with Autism by the treating Physician to include the
Spectrum Disorder prior to his or her 9th birthday diagnosis,the proposed treatment type,the
consisting of: frequency and duration of treatment,the
What Is Covered? 2-3
anticipated outcomes stated as goals,and the Contraceptive Injections
frequency with which the treatment plan will be Medication by injection is covered when
updated, but no less than every 6 months. This provided and administered by a Physician,for
benefit booklet will only cover services to the the purpose of contraception, and is limited to
extent included in the Treating Physician's the medication and administration when
formal written treatment plan. medically necessary.
Breast Reconstructive Surgery Dental Services
Surgery to reestablish symmetry between two Dental Services are limited to the following:
breasts and implanted prostheses incident to
Mastectomy is covered. In order to be covered, 1. Care and stabilization treatment rendered
such surgery must be provided in a manner within 90 days of an Accidental Dental Injury
chosen by your Physician, consistent with to Sound Natural Teeth.
prevailing medical standards,and in consultation 2. Extraction of teeth required prior to radiation
with you. therapy when you have a diagnosis of
cancer of the head and/or neck.
Child Cleft Lip and Cleft Palate Treatment
3. Anesthesia Services for dental care
Treatment and Services for Child Cleft Lip and including general anesthesia and
Cleft Palate, including medical,dental, Speech hospitalization Services necessary to assure
Therapy, audiology, and nutrition Services for
the safe delivery of necessary dental care
treatment of a child under the age of 18 who has provided to you or your Covered Dependent
cleft lip or cleft palate are covered. In order for in a Hospital or Ambulatory Surgical Center
such Services to be covered,your Covered
if:
Dependent's Physician must specifically
prescribe such Services and such Services must a) the Covered Dependent is under 8
be medically necessary and consequent to years of age and it is determined by a
treatment of the cleft lip or cleft palate. dentist and the Covered Dependent's
Physician that:
Concurrent Physician Care i. dental treatment is necessary due to
Concurrent Physician care Services are a dental Condition that is
covered, provided:(a)the additional Physician significantly complex; or
actively participates in your treatment; (b)the ii. the Covered Dependent has a
Condition involves more than one body system developmental disability in which
or is so severe or complex that one Physician patient management in the dental
cannot provide the care unassisted; and(c)the office has proven to be ineffective;
Physicians have different specialties or have the
or
same specialty with different sub-specialties.
b) you or your Covered Dependent have
Consultations one or more medical Conditions that
Consultations provided by a Physician are would create significant or undue
covered if your attending Physician requests the medical risk for you in the course of
consultation and the consulting Physician delivery of any necessary dental
prepares a written report. treatment or surgery if not rendered in a
Hospital or Ambulatory Surgical Center.
What Is Covered? 24
Exclusion: 4. approved machine testing(e.g.,
1. Dental Services provided more than 90 days electrocardiogram [EKG],
after the date of an Accidental Dental Injury electroencephalograph [EEG], and other
regardless of whether or not such services
electronic diagnostic medical procedures);
could have been rendered within 90 days; and
and 5. genetic testing for the purposes of
2. Dental Implant. explaining current signs and symptoms of a
possible hereditary disease.
Diabetes Outpatient Self-Management
Dialysis Services
Diabetes outpatient self-management training
and educational Services and nutrition Dialysis Services including equipment,training,
counseling(including all Medically Necessary and medical supplies,when provided at any
equipment and supplies)to treat diabetes, if location by a Provider licensed to perform
dialysis including a Dialysis Center are covered.
your treating Physician or a Physician who
specializes in the treatment of diabetes certifies Durable Medical Equipment
that such Services are Medically Necessary, are
covered. In order to be covered, diabetes Durable Medical Equipment when provided by a
outpatient self-management training and Durable Medical Equipment Provider and when
educational Services must be provided under prescribed by a Physician, limited to the most
the direct supervision of a certified Diabetes cost-effective equipment as determined by
Educator or a board-certified Physician BCBSF or Monroe County BOCC is covered.
specializing in endocrinology. Additionally, in Payment Guidelines for Durable Medical
order to be covered, nutrition counseling must Equipment
be provided by a licensed Dietitian. Covered
Services may also include the trimming of Supplies and service to repair medical
toenails,corns, calluses, and therapeutic shoes equipment may be Covered Services only if you
(including inserts and/or modifications)for the own the equipment or you are purchasing the
treatment of severe diabetic foot disease. equipment. Payment for Durable Medical
Equipment will be based on the lowest of the
Diagnostic Services following: 1)the purchase price; 2)the
Diagnostic Services when ordered by a lease/purchase price; 3)the rental rate;or 4)the
Physician are limited to the following: Allowed Amount. The Allowed Amount for such
rental equipment will not exceed the total
1. radiology, ultrasound and nuclear medicine, purchase price. Durable Medical Equipment
Magnetic Resonance Imaging(MRI);
� includes, but is not limited to,the following:
2. laboratory and pathology Services; wheelchairs, crutches,canes,walkers, hospital
3. Services involving bones or joints of the jaw beds, and oxygen equipment.
(e.g., Services to treat temporomandibular Note: Repair or replacement of Durable
joint[TMJ]dysfunction)or facial region if, Medical Equipment due to growth of a child or
under accepted medical standards, such significant change in functional status is a
diagnostic Services are necessary to treat Covered Service.
Conditions caused by congenital or Exclusion:
developmental deformity, disease,or injury;
Equipment which is primarily for convenience
and/or comfort; modifications to motor vehicles
What Is Covered? 2-5
and/or homes, including but not limited to, 3. the usual and customary Provider charges
wheelchair lifts or ramps;water therapy devices for similar Services in the community where
such as Jacuzzis, hot tubs, swimming pools or the Services were provided; or
whirlpools; exercise and massage equipment,
electric scooters, hearing aids, air conditioners 4. what Medicare would have paid for the
and purifiers, humidifiers,water softeners and/or Services rendered.
purifiers, pillows,mattresses or waterbeds, In no event will Out-of-Network Providers be
escalators,elevators, stair glides,emergency paid more than their charges for the Services
alert equipment, handrails and grab bars, heat rendered.
appliances, dehumidifiers, and the replacement
of Durable Medical Equipment solely because it Enteral Formulas
is old or used are excluded. Prescription and non-prescription enteral
formulas for home use when prescribed by a
Emergency Services Physician as necessary to treat inherited
Emergency Services for an Emergency Medical diseases of amino acid, organic acid,
Condition are covered when rendered In- carbohydrate or fat metabolism as well as
Network and Out-of-Network without the need malabsorption originating from congenital
for any prior authorization determination by us. defects present at birth or acquired during the
When Emergency Services and care for an neonatal period are covered.
Emergency Medical Condition are rendered by Coverage to treat inherited diseases of amino
an Out-of-Network Provider, any Copayment acid and organic acids,for you up to your 25th
and/or Coinsurance amount applicable to In- birthday, shall include coverage for food
Network Providers for Emergency Services will products modified to be low protein.
also apply to such Out-of-Network Provider.
Eye Care
Special Payment Rules for Non-Grandfathered
Plans Coverage includes the following Services:
The Patient Protection and Affordable Care Act 1. Physician Services, soft lenses or sclera
(PPACA)requires that non-grandfathered health shells,for the treatment of aphakic patients;
plans apply a specific method for determining 2. initial glasses or contact lenses following
the allowed amount for Emergency Services cataract surgery; and
rendered for an Emergency Medical Condition 3. Physician Services to treat an injury to or
by Providers who do not have a contract with us. disease of the eyes.
Payment for Emergency Services rendered by Exclusion:
an Out-of-Network Provider that has not entered
into an agreement with BCBSF to provide Health Care Services to diagnose or treat vision
access to a discount from the billed amount of problems which are not a direct consequence of
that Provider will be the greater of: trauma or prior ophthalmic surgery; eye
examinations; eye exercises or visual training;
1. the amount equal to the median amount eye glasses and contact lenses and their fitting
negotiated with all BCBSF In-Network are excluded. In addition to the above, any
Providers for the same Services; surgical procedure performed primarily to correct
2. the Allowed Amount as defined in the or improve myopia or other refractive disorders
Booklet; (e.g., radial keratotomy, PRK and LASIK)are
excluded.
What Is Covered? 2-6
i
Home Health Care 5. respiratory, or inhalation therapy(e.g.,
oxygen); and
The Home Health Care Services listed below
are covered when the following criteria are met: 6. Physical Therapy by a Physical Therapist,
Occupational Therapy by a Occupational
1. you are unable to leave your home without Therapist,and Speech Therapy by a
considerable effort and the assistance of Speech Therapist.
another person because you are: bedridden
or chairbound or because you are restricted Exclusions:
in ambulation whether or not you use 1. homemaker or domestic maid services;
assistive devices; or you are significantly
2. sitter or companion services;
limited in physical activities due to a
Condition; and 3. Services rendered by an employee or
operator of an adult congregate living
2. the Home Health Care Services rendered facility;an adult foster home; an adult day !
have been prescribed by a Physician by way
care center, or a nursing home facility;
of a formal written treatment plan that has
been reviewed and renewed by the 4. Speech Therapy provided for a diagnosis of
prescribing Physician every 30 days. In developmental delay;
order to determine whether such Services 5. Custodial Care except for any such care
are covered under this Booklet, you may be covered under this subsection when
required to provide a copy of any written provided on a part-time or intermittent basis
treatment plan; (as defined above)by a home health aide;
3. the Home Health Care Services are 6. food, housing, and home delivered meals; j
provided directly by(or indirectly through)a and
Home Health Agency; and
7. Services rendered in a Hospital, nursing
4. you are meeting or achieving the desired home,or intermediate care facility.
treatment goals set forth in the treatment
plan as documented in the clinical progress Hospice Services
notes.
Health Care Services provided in connection
Home Health Care Services are limited to: with a Hospice treatment program may be
1. part-time(i.e., less than 8 hours per day and Covered Services, provided the Hospice
less than a total of 40 hours in a calendar treatment program is:
j week)or intermittent(i.e., a visit of up to, but 1. approved by your Physician; and
not exceeding, 2 hours per day)nursing
care by a Registered Nurse, Licensed 2. your doctor has certified to us in writing that
Practical Nurse and/or home health aide your life expectancy is 12 months or less.
j Services; Recertification is required every six months.
2. home health aide Services must be Hospital Services
consistent with the plan of treatment,
ordered by a Physician, and rendered under Covered Hospital Services include:
the supervision of a Registered Nurse; 1. room and board in a semi-private room
3. medical social services; when confined as an inpatient, unless the
patient must be isolated from others for
4. nutritional guidance; documented clinical reasons;
I
What Is Covered? 2-7
2. intensive care units, including cardiac, 3. take-home drugs;
progressive and neonatal care; 4. telephone and television;
3. use of operating and recovery rooms; 5. guest meals or gourmet menus; and
4. use of emergency rooms;
6. admission kits.
5. respiratory, pulmonary, or inhalation therapy
(e.g., oxygen); Inpatient Rehabilitation
6. drugs and medicines administered(except Inpatient Rehabilitation Services are covered
for take home drugs)by the Hospital; when the following criteria are met:
7. intravenous solutions; 1. Services must be provided under the
direction of a Physician and must be
8. administration of, including the cost of, provided by a Medicare certified facility in
whole blood or blood products except as
outlined in the Drugs exclusion of the"What accordance with a comprehensive
i
Is Not Covered?" section); rehabilitation program;
2
9. dressings, including ordinary casts; . a plan of care must be developed and
managed by a coordinated multi-disciplinary
10. anesthetics and their administration; team;
11. transfusion supplies and equipment; 3. coverage is limited to the specific acute,
12. diagnostic Services, including radiology, catastrophic target diagnoses of severe
ultrasound, laboratory, pathology and stroke, multiple trauma, brain/spinal injury,
approved machine testing(e.g., EKG); severe neurological motor disorders, and/or
severe burns;
13. Physical, Speech, Occupational, and
Cardiac Therapies; and 4. the individual must be able to actively
participate in at least 2 rehabilitative
14. transplants as described in the Transplant therapies and be able to tolerate at least 3
Services subsection. hours per day of skilled Rehabilitation
Exclusion: Services for at least 5 days a week and their
Condition must be likely to result in
Expenses for the following Hospital Services are significant improvement; and
excluded when such Services could have been
provided without admitting you to the Hospital: 5. the Rehabilitation Services must be required
1)room and board provided during the at such intensity,frequency and duration as
admission;2)Physician visits provided while you to make it impractical for the individual to
were an inpatient; 3)Occupational Therapy, receive services in a less intensive setting.
Speech Therapy, Physical Therapy, and Cardiac Inpatient Rehabilitation Services are subject to
Therapy;and 4)other Services provided while the inpatient facility Copayment, if applicable,
you were an inpatient. and the benefit maximum set forth in the
In addition, expenses for the following and Schedule of Benefits.
similar items are also excluded: Exclusion:
1. gowns and slippers; All Substance Dependency, drug and alcohol
2. shampoo,toothpaste, body lotions and related diagnoses, Pain Management, and
hygiene packets; respiratory ventilator management Services are
excluded.
What Is Covered? 2-8
Mammograms this Booklet for the postpartum assessment
Mammograms obtained in a medical office, includes coverage for the physical assessment
medical treatment facility or through a health of the mother and any necessary clinical tests in
testing service that uses radiological equipment keeping with prevailing medical standards.
registered with the appropriate Florida regulatory Under Federal law,your Group Plan generally
agencies(or those of another state)for may not restrict benefits for any hospital length
diagnostic purposes or breast cancer screening of stay in connection with childbirth for the
are Covered Services. mother or newborn child to less than 48 hours
Benefits for mammograms may not be subject to following a vaginal delivery; or less than 96
the Deductible, Coinsurance, or Copayment(if hours following a cesarean section. However,
applicable). Please refer to your Schedule of Federal law generally does not prohibit the
Benefits for more information. mother's or newborn's attending Provider, after
consulting with the mother,from discharging the
Mastectomy Services mother or her newborn earlier than 48 hours(or
96 as applicable). In any case, under Federal
Breast cancer treatment including treatment for law, your Group Plan can only require that a
physical complications relating to a Mastectomy provider obtain authorization for prescribing an
(including Iymphedemas), and outpatient post- inpatient hospital stay that exceeds 48 hours(or
surgical follow-up in accordance with prevailing 96 hours).
medical standards as determined by you and
your attending Physician are covered. Exclusion:
Outpatient post-surgical follow-up care for Maternity Services rendered to a Covered
Mastectomy Services shall be covered when Person who becomes pregnant as a Gestational
provided by a Provider in accordance with the Surrogate under the terms of, and in accordance
prevailing medical standards and at the most with, a Gestational Surrogacy Contract or
medically appropriate setting. The setting may Arrangement are excluded. This exclusion
be the Hospital, Physician's office, outpatient applies to all expenses for prenatal, intra-partal,
center, or your home. The treating Physician, and post-partal Maternity/Obstetrical Care, and
after consultation with you, may choose the Health Care Services rendered to the Covered
appropriate setting. Person acting as a Gestational Surrogate.
Maternity Services For the definition of Gestational Surrogate and
Gestational Surrogacy Contract, see the
Health Care Services, including prenatal care, "Definitions" section of this Benefit Booklet.
delivery and postpartum care and assessment,
provided to you, by a Doctor of Medicine(M.D.), Medical Pharmacy
Doctor of Osteopathy(D.O.), Hospital, Birth
Center, Midwife or Certified Nurse Midwife may Physician-administered Prescription Drugs
be Covered Services. Care for the mother which are rendered in a Physician's office are
includes the postpartum assessment. subject to a separate Cost Share amount that is
in addition to the office visit Cost Share amount.
In order for the postpartum assessment to be The Medical Pharmacy Cost Share amount
covered, such assessment must be provided at applies to the Prescription Drug and does not
a Hospital, an attending Physician's office, an include the administration of the Prescription
outpatient maternity center, or in the home by a Drug.
qualified licensed health care professional
trained in care for a mother. Coverage under
What Is Covered? 2-9
Your plan may also include a maximum monthly of learning disabilities or for mental
amount you will be required to pay out-of-pocket retardation;
for Medical Pharmacy, when such Services are 3. Services extended beyond the period
provided by an In-Network Provider or Specialty necessary for evaluation and diagnosis of
Pharmacy. If your plan includes a Medical learning disabilities or for mental retardation;
Pharmacy out-of-pocket monthly maximum, it
will be listed on your Schedule of Benefits and 4. Services for marriage counseling,when not
only applies after you have met your Deductible, rendered in connection with a Condition
if applicable. classified in the diagnostic categories of the
International Classification of Diseases,
Please refer to your Schedule of Benefits for the Ninth Edition,Clinical Modification(ICD-9-
additional Cost Share amount and/or monthly CM)or their equivalents in the most recently
maximum out-of-pocket applicable to Medical published version of the American
Pharmacy for your plan. Psychiatric Association's Diagnostic and
Note: For purposes of this benefit, allergy Statistical Manual of Mental Disorders;
injections and immunizations are not considered 5. Services for pre-marital counseling;
Medical Pharmacy. 6. Services for court-ordered care or testing, or
Mental Health Services required as a condition of parole or
probation;
Diagnostic evaluation, psychiatric treatment,
individual therapy, and group therapy provided �• Services for testing of aptitude, ability,
to you by a Physician, Psychologist, or Mental intelligence or interest(except as covered
Health Professional for the treatment of a Mental under the Autism Spectrum Disorder
and Nervous Disorder may be covered. These subsection);
Health Care Services include inpatient, 8. Services for testing and evaluation for the
outpatient, and Partial Hospitalization services. purpose of maintaining employment;
Partial Hospitalization is a Covered Service 9. Services for cognitive remediation;
when provided under the direction of a Physician 10. inpatient confinements that are primarily
and in lieu of inpatient hospitalization. intended as a change of environment;or
Exclusion: 11. inpatient(over night)mental health Services
1. Services rendered in connection with a received in a residential treatment facility.
Condition not classified in the diagnostic Newborn Care
categories of the International Classification
of Diseases, Ninth Edition, Clinical A newborn child will be covered from the
Modification(ICD-9 CM)or their equivalents moment of birth provided that the newborn child
in the most recently published version of the is eligible for coverage and properly enrolled.
American Psychiatric Association's Covered Services shall consist of coverage for
Diagnostic and Statistical Manual of Mental injury or sickness, including the necessary care
Disorders, regardless of the underlying or treatment of medically diagnosed congenital
cause,or effect, of the disorder; defects, birth abnormalities, and premature birth.
2. Services for psychological testing Newborn Assessment:
associated with the evaluation and diagnosis An assessment of the newborn child is covered
provided the Services were rendered at a
What Is Covered? 2-10
Hospital,the attending Physician's office, a Birth Payment for splints for the treatment of
Center, or in the home by a Physician, Midwife temporomandibular joint("TMJ")dysfunction is
or Certified Nurse Midwife, and the performance limited to payment for one splint in a six-month
of any necessary clinical tests and period unless a more frequent replacement is
immunizations are within prevailing medical determined by BCBSF or Monroe County BOCC
standards. These Services are not subject to to be Medically Necessary.
the Deductible.
Exclusion:
Ambulance Services,when necessary to 1. Expenses for arch supports,shoe inserts
transport the newborn child to and from the designed to effect conformational changes
nearest appropriate facility which is staffed and in the foot or foot alignment, orthopedic
equipped to treat the newborn child's Condition, shoes, over-the-counter, custom-made or
as determined by BCBSF or Monroe County
built-up shoes,cast shoes, sneakers,ready-
BOCC and certified by the attending Physician
as Medically Necessary to protect the health and made compression hose or support hose, or
similar type devices/appliances regardless
safety of the newborn child, are covered.
of intended use, except for therapeutic
Under Federal law, your Group Plan generally shoes(including inserts and/or
may not restrict benefits for any hospital length modifications)for the treatment of severe
of stay in connection with childbirth for the diabetic foot disease;
mother or newborn child to less than 48 hours 2. Expenses for orthotic appliances or devices
following a vaginal delivery; or less than 96 which straighten or re-shape the
hours following a cesarean section. However, conformation of the head or bones of the
Federal law generally does not prohibit the skull or cranium through cranial banding or
mother's or newborn's attending Provider,after molding(e.g. dynamic orthotic cranioplasty
consulting with the mother,from discharging the or molding helmets), except when the
mother or her newborn earlier than 48 hours(or orthotic appliance or device is used as an
96 as applicable). In any case, under Federal alternative to an internal fixation device as a
law, your Group Plan can only require that a result of surgery for craniosynostosis; and
provider obtain authorization for prescribing an 3. Expenses for devices necessary to exercise,
inpatient hospital stay that exceeds 48 hours(or
train, or participate in sports,e.g.custom-
96 hours). made knee braces.
Orthotic Devices Osteoporosis Screening, Diagnosis, and
Orthotic Devices including braces and trusses Treatment
for the leg,arm, neck and back,and special Screening, diagnosis, and treatment of
surgical corsets are covered when prescribed by osteoporosis for high-risk individuals is covered
a Physician and designed and fitted by an as medically necessary, including, but not
Orthotist. limited to:
Benefits may be provided for necessary 1. estrogen-deficient individuals who are at
replacement of an Orthotic Device which is clinical risk for osteoporosis;
owned by you when due to irreparable damage,
wear, a change in your Condition, or when 2. individuals who have vertebral
necessitated due to growth of a child. abnormalities;
3. individuals who are receiving long-term
glucocorticoid(steroid)therapy; or
What Is Covered? 2-11
4. individuals who have primary 458(Medical Practice), Chapter 459
hyperparathyroidism, and (Osteopathy), Chapter 460(Chiropractic)or
5. individuals who have a family history of Chapter 461 (Podiatry)is covered. The
osteoporosis. Physician's prescription must specify the
number of treatments.
Outpatient Cardiac,Occupational, Physical, Payment Guidelines for Massage and
Speech, Massage Therapies and Spinal Physical Therapy
Manipulation Services
1. Payment for covered Massage Services is
Outpatient therapies listed below may be limited to no more than four(4) 15-minute
Covered Services when ordered by a Physician Massage treatments per day, not to exceed
or other health care professional licensed to the Outpatient Cardiac, Occupational,
perform such Services. The outpatient therapies Physical, Speech, and Massage Therapies
listed in this category are in addition to the and Spinal Manipulations benefit maximum
Cardiac, Occupational, Physical and Speech listed on the Schedule of Benefits.
Therapy benefits listed in the Home Health
Care, Hospital, and Skilled Nursing Facility 2. Payment for a combination of covered
categories herein. Massage and Physical Therapy Services
rendered on the same day is limited to no
Cardiac Therapy Services provided under the more than four(4) 15-minute treatments per
supervision of a Physician,or an appropriate day for combined Massage and Physical
Provider trained for Cardiac Therapy,for the Therapy treatment,not to exceed the
purpose of aiding in the restoration of normal Outpatient Cardiac, Occupational, Physical,
heart function in connection with a myocardial Speech, and Massage Therapies and Spinal
infarction, coronary occlusion or coronary Manipulations benefit maximum listed on the
bypass surgery are covered. Schedule of Benefits.
Occupational Therapy Services provided by a 3. Payment for covered Physical Therapy
Physician or Occupational Therapist for the Services rendered on the same day as
purpose of aiding in the restoration of a spinal manipulation is limited to one(1)
previously impaired function lost due to a Physical Therapy treatment per day not to
Condition are covered. exceed fifteen(15)minutes in length.
Speech Therapy Services of a Physician, Spinal Manipulations: Services by Physicians
Speech Therapist, or licensed audiologist to aid for manipulations of the spine to correct a slight
in the restoration of speech loss or an dislocation of a bone or joint that is
impairment of speech resulting from a Condition demonstrated by x-ray are covered.
are covered.
Payment Guidelines for Spinal Manipulation
Physical Therapy Services provided by a
Physician or Physical Therapist for the purpose 1• Payment for covered spinal manipulation is
of aiding in the restoration of normal physical limited to no more than 26 spinal
function lost due to a Condition are covered. manipulations per Benefit Period, or the
maximum benefit listed in the Schedule of
Massage Therapy Massage provided by a Benefits,whichever occurs first.
Physician, Massage Therapist, or Physical
Therapist when the Massage is prescribed as 2. Payment for covered Physical Therapy
being Medically Necessary by a Physician Services rendered on the same day as a
licensed pursuant to Florida Statutes Chapter spinal manipulation is limited to one(1)
What Is Covered? 2-12
Physical Therapy treatment per day, not to services vendor that, at the time the
exceed fifteen(15)minutes in length. Services were rendered,was under contract
Your Schedule of Benefits sets forth the with BCBSF.
maximum number of visits covered under this The term "established patient,"as used herein,
plan for any combination of the outpatient shall mean that the covered individual has
therapies and spinal manipulation Services received professional services from the
listed above. For example, even if you may Physician who provided the online medical
have only been administered two(2)of the Services, or another physician of the same
spinal manipulations for the Benefit Period, any specialty who belongs to the same group
additional spinal manipulations for that Benefit practice as that Physician,within the past three
Period will not be covered if you have already years.
met the combined therapy visit maximum with Exclusion:
other Services.
Expenses for online medical Services provided
Oxygen electronically through a computer by a Physician
Expenses for oxygen,the equipment necessary via the Internet other than through a healthcare
to administer it, and the administration of oxygen communication services vendor that has entered
are covered. into contract with BCBSF are excluded.
Expenses for online medical Services provided
Physician Services by a health care provider that is not a Physician
and expenses for Health Care Services
Medical or surgical Health Care Services rendered by telephone are also excluded.
provided by a Physician, including Services
rendered in the Physician's office, in an Preventive Health Services
outpatient facility, or electronically through a Preventive Services are covered for both adults
computer via the Internet.
and children based on prevailing medical
Payment Guidelines for Physician Services standards and recommendations which are
Provided by Electronic Means through a explained further below. Some examples of
Computer: preventive health Services include, but are not
limited to, periodic routine health exams, routine
Expenses for online medical Services provided gynecological exams, immunizations and related
electronically through a computer by a Physician preventive Services such as Prostate Specific
via the Internet will be covered only if such Antigen(PSA), routine mammograms and pap
Services: smears. In order to be covered, Services shall
1. were provided to a covered individual who be provided in accordance with prevailing
was,at the time the Services were provided, medical standards consistent with:
an established patient of the Physician
rendering the Services; 1. evidence-based items or Services that have
in effect a rating of'A' or'B' in the current
2. were in response to an online inquiry recommendations of the U.S. Preventive
received through the Internet from the Services Task Force established under the
covered individual with respect to which the Public Health Service Act;
Services were provided; and
2. immunizations that have in effect a
3. were provided by a Physician through a recommendation from the Advisory
secure online healthcare communication Committee on Immunization Practices of the
What Is Covered? 2-13
Centers for Disease Control and Prevention uterine devices(IUD)only, including insertion
established under the Public Health Service and removal.
Act with respect to the individual involved; prosthetic Devices
3. with respect to infants, children, and The following Prosthetic Devices are covered
adolescents,evidence-informed preventive when prescribed by a Physician and designed
care and screenings provided for in the and fitted by a Prosthetist:
comprehensive guidelines supported by the
Health Resources and Services 1. artificial hands,arms,feet, legs and eyes,
Administration; and including permanent implanted lenses
following cataract surgery, cardiac
4. with respect to women, such additional pacemakers,and prosthetic devices incident
preventive care and screenings not
described in paragraph number one as to a Mastectomy;
provided for in comprehensive guidelines 2. appliances needed to effectively use artificial
supported by the Health Resources and limbs or corrective braces; or
Services Administration. Women's 3. penile prosthesis.
preventive coverage under this category
Covered Prosthetic Devices(except cardiac
includes:
pacemakers, and Prosthetic Devices incident to
a. well-woman visits; Mastectomy)are limited to the first such
b. screening for gestational diabetes; permanent prosthesis(including the first
temporary prosthesis if it is determined to be
c. human papillomavirus testing; necessary)prescribed for each specific
d. counseling for sexually transmitted Condition.
infections; Benefits may be provided for necessary
e. counseling and screening for human replacement of a Prosthetic Device which is
immune-deficiency virus; owned by you when due to irreparable damage,
f. contraceptive methods and counseling; wear, or a change in your Condition, or when
necessitated due to growth of a child.
g. screening and counseling for
interpersonal and domestic violence; Exclusion:
and 1. Expenses for microprocessor controlled or
h. breastfeeding support, supplies and myoelectric artificial limbs(e.g. C-legs); and
counseling. Breastfeeding supplies are 2. Expenses for cosmetic enhancements to
limited to one manual breast pump per
artificial limbs.
pregnancy.
Exclusion: Self-Administered Prescription Drugs
Routine vision and hearing examinations and The following Self-Administered Drugs are
screenings are not covered, except as required covered:
under paragraph number one above. 1. Self-Administered Prescription Drugs used
Sterilization procedures covered under this in the treatment of diabetes,cancer,
section are limited to tubal ligations only. Conditions requiring immediate stabilization
Contraceptive implants are limited to Intra-
What Is Covered? 2-14
(e.g.anaphylaxis),or in the administration of Skilled Nursing Facilities
dialysis;and
The following Health Care Services may be
2. Self-Administered Prescription Drugs Covered Services when you are an inpatient in a
identified as Specialty Drugs with a special Skilled Nursing Facility:
symbol in the Medication Guide when
delivered to you at home and purchased at a 1. room and board;
Specialty Pharmacy or an Out-of-Network 2. respiratory, pulmonary, or inhalation therapy
Provider that provides Specialty Drugs. (e.g.,oxygen);
3. Specialty Drugs used to increase height or 3. drugs and medicines administered while an
bone growth (e.g., growth hormone), must inpatient(except take home drugs);
meet the following criteria in order to be 4. intravenous solutions;
covered:
5. administration of, including the cost of,
a. Must be prescribed for Conditions of whole blood or blood products(except as
growth hormone deficiency documented outlined in the Drugs exclusion of the"What
with two abnormally low stimulation Is Not Covered?"section);
tests of less than 10 ng/ml and one
6. dressings, including ordinary casts;
abnormally low growth hormone
dependent peptide or for Conditions of 7. transfusion supplies and equipment;
growth hormone deficiency associated g. diagnostic Services, including radiology,
with loss of pituitary function due to ultrasound, laboratory, pathology and
trauma, surgery,tumors, radiation or approved machine testing(e.g., EKG);
disease, or for state mandated use as in
patients with AIDS. 9. chemotherapy treatment for proven
malignant disease; and
b. Continuation of growth hormone therapy
is only covered for Conditions 10. Physical, Speech, and Occupational
associated with significant growth Therapies.
hormone deficiency when there is A treatment plan from your Physician may be
evidence of continued responsiveness required in order to determine coverage and
to treatment. Treatment is considered payment.
responsive in children less than 21 Exclusion:
years of age,when the growth hormone
dependent peptide(IGF-1)is in the Expenses for an inpatient admission to a Skilled
normal range for age and Tanner Nursing Facility for purposes of Custodial Care,
development stage; the growth velocity convalescent care, or any other Service
is at least 2 cm per year, and studies primarily for the convenience of you and/or your
family members or the Provider are excluded.
demonstrate open epiphyses.
Treatment is considered responsive in Substance Dependency Care and Treatment
both adolescents with closed epiphyses
and for adults,who continue to evidence Care and treatment for Substance Dependency
growth hormone deficiency and the IGF- includes the following:
1 remains in the normal range for age 1. Health Care Services(inpatient and
and gender. outpatient or any combination thereof)
provided by a Physician, Psychologist or
What Is Covered? 2-15
Mental Health Professional in a program congenital or developmental deformity,
accredited by the Joint Commission on the disease, or injury;
Accreditation of Healthcare Organizations or 5. Services of a Physician for the purpose of
approved by the state of Florida(or another rendering a second surgical opinion and
state)for Detoxification or Substance related diagnostic services to help determine
Dependency. the need for sure and
surgery;
2. Physician, Psychologist and Mental Health 6. surgical procedures performed on a Covered
Professional outpatient visits for the care Plan Participant for the treatment of Morbid
and treatment of Substance Dependency. Obesity(e.g., intestinal bypass, stomach
Exclusion: stapling, balloon dilation)and the associated
care provided the Covered Plan Participant
Expenses for prolonged care and treatment of has not previously undergone the same or
Substance Dependency in a specialized similar procedure in the lifetime of this
inpatient or residential facility or inpatient Group Health Plan when medically
confinements that are primarily intended as a necessary.
change of environment are excluded.
Exclusion:
Surgical Assistant Services a. Surgical procedures for the treatment of
Services rendered by a Physician, Registered Morbid Obesity including: intestinal
Nurse First Assistant or Physician Assistant bypass; stomach stapling; balloon
when acting as a surgical assistant(provided no dilation and associated care for the
intern, resident, or other staff physician is surgical treatment of Morbid Obesity, if
available)when the assistant is necessary are the Covered Plan Participant has
covered. previously undergone the same or
similar procedures in the lifetime of this
Surgical Procedures Group Health Plan. Surgical procedures
Surgical procedures performed by a Physician performed to revise, or correct defects
may be covered including the following: related to, a prior intestinal bypass,
1. sterilization (tubal ligations and stomach stapling or balloon dilation are
also excluded.
vasectomies), regardless of Medical
Necessity; b. Reversal of a weight loss surgery,
2. surgery to correct deformity which was surgical procedures to revise,correct,
and correction of defects to include
caused by disease, trauma, birth defects, adjustment to devices implanted or any
growth defects or prior therapeutic fills not performed during the initial
processes;
surgical event.
3. oral surgical procedures for excisions of Payment Guidelines for Surgical Procedures
tumors, cysts, abscesses,and lesions of the
mouth; 1. Payment for multiple surgical procedures
performed in addition to the primary surgical
4. surgical procedures involving bones or joints procedure, on the same or different areas of
of the jaw(e.g.,temporomandibular joint
the body, during the same operative session
[TMJ])and facial region if, under accepted will be based on 50 percent of the Allowed
medical standards, such surgery is Amount for any secondary surgical
necessary to treat Conditions caused by
procedure(s)performed. In addition,
What Is Covered? 2-16
Coinsurance or Copayment(if any)indicated any successor or similar rule or covered by
in your Schedule of Benefits will apply. This Medicare as described in the most recently
guideline is applicable to all bilateral published Medicare Coverage Issues
procedures and all surgical procedures Manual issued by the Centers for Medicare
performed on the same date of service. and Medicaid Services. Coverage will be
2. Payment for incidental surgical procedures provided for the expenses incurred for the
is limited to the Allowed Amount for the donation of bone marrow by a donor to the
primary procedure, and there is no same extent such expenses would be
additional payment for any incidental covered for you and will be subject to the
procedure. An "incidental surgical same limitations and exclusions as would be
procedure" includes surgery where one, or applicable to you. Coverage for the
more than one, surgical procedure is reasonable expenses of searching for the
performed through the same incision or donor will be limited to a search among
operative approach as the primary surgical immediate family members and donors
procedure which, in BCBSF's or Monroe identified through the National Bone Marrow
County BOCC's opinion, is not clearly Donor Program;
identified and/or does not add significant
time or complexity to the surgical session. 2. corneal transplant;
For example,the removal of a normal 3. heart transplant(including a ventricular
appendix performed in conjunction with a assist device, if indicated, when used as a
Medically Necessary hysterectomy is an bridge to heart transplantation);
incidental surgical procedure(i.e.,there is
no payment for the removal of the normal 4. heart-lung combination transplant;
appendix in the example). 5. liver transplant;
3. Payment for surgical procedures for fracture 6. kidney transplant;
care, dislocation treatment, debridement,
wound repair, unna boot, and other related 7. Pancreas;
Health Care Services, is included in the 8. pancreas transplant performed
Allowed Amount of the surgical procedure. simultaneously with a kidney transplant; or
Transplant Services 9. lung-whole single or whole bilateral
transplant.
Transplant Services, limited to the procedures
listed below, may be covered when performed at Coverage will be provided for donor costs and
a facility acceptable to BCBSF or Monroe organ acquisition for transplants, other than
County BOCC, subject to the conditions and Bone Marrow Transplants, provided such costs
limitations described below. are not covered in whole or in part by any other
Transplant includes pre-transplant, transplant insurance carrier, organization or person other
and post-discharge Services, and treatment of than the donor's family or estate.
complications after transplantation. Benefits will You may call the customer service phone
only be paid for Services, care and treatment number indicated in this Booklet or on your
received or provided in connection with a: Identification Card in order to determine which
1. Bone Marrow Transplant, as defined herein, Bone Marrow Transplants are covered under
which is specifically listed in the rule 596- this Booklet.
12.001 of the Florida Administrative Code or
What Is Covered? 2-17
Exclusions:
Expenses for the following are excluded:
1. transplant procedures not included in the list
above, or otherwise excluded under this
Booklet(e.g., Experimental or Investigational
transplant procedures);
2. transplant procedures involving the
transplantation or implantation of any non-
human organ or tissue;
3. transplant procedures related to the donation
or acquisition of an organ or tissue for a
recipient who is not covered under this
Benefit Booklet;
4. transplant procedures involving the implant of
an artificial organ, including the implant of the
artificial organ;
5. any organ,tissue, marrow, or stem cells
which is/are sold rather than donated;
6. any Bone Marrow Transplant,as defined
herein,which is not specifically listed in rule
5913-12.001 of the Florida Administrative
Code or any successor or similar rule or
covered by Medicare pursuant to a national
coverage decision made by the Centers for
Medicare and Medicaid Services as
evidenced in the most recently published
Medicare Coverage Issues Manual;
7. any Service in connection with the
identification of a donor from a local, state or
national listing, except in the case of a Bone
Marrow Transplant;
8. any non-medical costs, including but not
limited to,temporary lodging or transportation
costs for you and/or your family to and from
the approved facility; and
9. any artificial heart or mechanical device that
replaces either the atrium and/or the
ventricle.
What Is Covered? 2-18
Section 3: What Is Not Covered?
Introduction clinical ecology;chelation therapy;
thermography; mind-body interactions such as
Your Booklet expressly excludes expenses for meditation, imagery, yoga, dance, and art
the following Health Care Services, supplies, therapy; biofeedback; prayer and mental
drugs or charges. The following exclusions are healing; manual healing methods such as the
in addition to any exclusions specified in the Alexander technique, aromatherapy, Ayurvedic
'What Is Covered?"section or any other section massage, craniosacral balancing, Feldenkrais
of the Booklet. method, Hellerwork, polarity therapy, Reichian
Abortions which are elective. therapy, reflexology, rolfing, shiatsu,traditional
Chinese massage,Trager therapy,trigger-point
Arch Supports, shoe inserts designed to effect myotherapy, and biofield therapeutics; Reiki,
conformational changes in the foot or foot SHEN therapy, and therapeutic touch;
alignment,orthopedic shoes,over-the-counter, bioelectromagnetic applications in medicine;and
custom-made or built-up shoes, cast shoes, herbal therapies.
sneakers, ready-made compression hose or
support hose, or similar type devices/appliances Complications of Non-Covered Services,
regardless of intended use, except for including the diagnosis or treatment of any
therapeutic shoes(including inserts and/or Condition which is a complication of a non-
modifications)for the treatment of severe covered Health Care Service(e.g., Health Care
diabetic foot disease. Services to treat a complication of cosmetic
surgery are not covered).
Assisted Reproductive Therapy(Infertility)
including, but not limited to, associated Services, Contraceptive medications, devices,
supplies, and medications for In Vitro appliances, or other Health Care Services when
Fertilization(IVF); Gamete Intrafallopian provided for contraception, except when
Transfer(GIFT)procedures; Zygote indicated as covered, under the Preventive
Intrafallopian Transfer(ZIFT)procedures; Health Services category of the"What Is
Artificial Insemination(AI); embryo transport; Covered?" section.
surrogate parenting;donor semen and related Cosmetic Services, including any Service to
costs including collection and preparation; and improve the appearance or self-perception of an
infertility treatment medication. individual(except as covered under the Breast
Autopsy or postmortem examination services, Reconstructive Surgery category), including and
unless specifically requested by BCBSF or without limitation: cosmetic surgery and
Monroe County BOCC. procedures or supplies to correct hair loss or
skin wrinkling(e.g., Minoxidil, Rogaine, Retin-A),
Complementary or Alternative Medicine and hair implants/transplants.
including, but not limited to, self-care or self-help
training; homeopathic medicine and counseling; Costs related to telephone consultations, failure
Ayurvedic medicine such as lifestyle to keep a scheduled appointment, or completion
modifications and purification therapies; of any form and/or medical information.
traditional Oriental medicine including Custodial Care and any service of a custodial
acupuncture; naturopathic medicine; nature, including and without limitation: Health
environmental medicine including the field of Care Services primarily to assist in the activities
What Is Not Covered? 3-1
of daily living; rest homes; home companions or treatment of cancer that have not been
sitters; home parents;domestic maid services; approved for any indication are excluded.
respite care; and provision of services which are. 2. All drugs dispensed to, or purchased by, you
for the sole purposes of allowing a family
from a pharmacy. This exclusion does not
member or caregiver of a Covered Person to apply to drugs dispensed to you when:
return to work.
a. you are an inpatient in a Hospital,
Dental Care or treatment of the teeth or their Ambulatory Surgical Center, Skilled
supporting structures or gums, or dental Nursing Facility, Psychiatric Facility or a
procedures, including but not limited to: Hospice facility;
extraction of teeth, restoration of teeth with or
without fillings,crowns or other materials, b. you are in the outpatient department of
bridges,cleaning of teeth, dental implants, a Hospital;
dentures, periodontal or endodontic procedures, c. dispensed to your Physician for
orthodontic treatment(e.g., braces), intraoral administration to you in the Physician's
prosthetic devices, palatal expansion devices, office and prior coverage authorization
bruxism appliances, and dental x-rays. This has been obtained(if required); and
exclusion also applies to Phase II treatments(as
defined by the American Dental Association)for d. you are receiving Home Health Care
TMJ dysfunction. This exclusion does not apply according to a plan of treatment and the
to an Accidental Dental Injury and the Child Cleft Home Health Care Agency bills us for
Lip and Cleft Palate Treatment Services such drugs, including Self-Administered
Prescription Drugs that are rendered in
category as described in the"What Is Covered?"
connection with a nursing visit.
section.
3. Any non-Prescription medicines, remedies,
Drugs vaccines, biological products(except
1. Prescribed for uses other than the Food and insulin), pharmaceuticals or chemical
Drug Administration(FDA)approved label compounds, vitamins, mineral supplements,
indications. This exclusion does not apply to fluoride products, over-the-counter drugs,
any drug that has been proven safe, products,or health foods, except as
effective and accepted for the treatment of described in the Preventive Health Services
the specific medical Condition for which the category of the"What Is Covered?"section.
drug has been prescribed, as evidenced by
the results of good quality controlled clinical 4. Any drug which is indicated or used for
studies published in at least two or more sexual dysfunction(e.g., Cialis, Levitra,
peer-reviewed full length articles in Viagra, Caverject). The exception described
respected national professional medical in exclusion number one above does not
journals. This exclusion also does not apply apply to sexual dysfunction drugs excluded
to any drug prescribed for the treatment of under this paragraph.
cancer that has been approved by the FDA 5. Any Self-Administered Prescription Drug not
for at least one indication, provided the drug indicated as covered in the"What Is
is recognized for treatment of your particular Covered?" section of this Benefit Booklet.
cancer in a Standard Reference 6. Blood or blood products used to treat
Compendium or recommended for treatment hemophilia, except when provided to you
of your particular cancer in Medical for:
Literature. Drugs prescribed for the
I
What Is Not Covered? 3-2
a. emergency stabilization; arches; chronic foot strain;trimming of toenails
b. during a covered inpatient stay; or corns,or calluses.
c. when proximately related to a surgical General Exclusions include, but are not limited
procedure. to:
The exceptions to the exclusion for drugs 1. any Health Care Service received prior to
purchased or dispensed by a pharmacy your Effective Date or after the date your
described in subparagraph number two do coverage terminates;
not apply to hemophilia drugs excluded 2. any Service to diagnose or treat any
under this subparagraph. Condition resulting from or in connection
7. Drugs,which require prior coverage with your job or employment;
authorization when prior coverage 3. any Health Care Services not within the
authorization is not obtained. service categories described in the"What is
8. Specialty Drugs used to increase height or Covered?"section, any rider, or
bone growth(e.g., growth hormone)except Endorsement attached hereto, unless such
for Conditions of growth hormone deficiency services are specifically required to be
documented with two abnormally low covered by applicable law;
stimulation tests of less than 10 ng/ml and 4. any Health Care Services provided by a
one abnormally low growth hormone Physician or other health care Provider
dependent peptide or for Conditions of related to you by blood or marriage;
growth hormone deficiency associated with
loss of pituitary function due to trauma, 5. any Health Care Service which is not
surgery,tumors,radiation or disease, or for Medically Necessary as determined by us or
state mandated use as in patients with Monroe County BOCC and defined in this
AIDS. Booklet. The ordering of a Service by a
health care Provider does not in itself make
Continuation of growth hormone therapy will such Service Medically Necessary or a
not be covered except for Conditions Covered Service;
associated with significant growth hormone
deficiency when there is evidence of 6. any Health Care Services rendered at no
continued responsiveness to treatment. charge;
(See"What is Covered?"section for 7. expenses for claims denied because we did
additional information.) not receive information requested from you
Experimental or Investigational Services, regarding whether or not you have other
except as otherwise covered under the Bone coverage and the details of such coverage;
Marrow Transplant provision of the Transplant 8. any Health Care Services to diagnose or
Services category. treat a Condition which,directly or indirectly,
Food and Food Products prescribed or not, resulted from or is in connection with:
except as covered in the Enteral Formulas a) war or an act of war, whether declared
subsection of the"What Is Covered?" section. or not;
Foot Care which is routine, including any Health b) your participation in, or commission of,
Care Service, in the absence of disease. This any act punishable by law as a
exclusion includes, but is not limited to: non- misdemeanor or felony, or which
surgical treatment of bunions;flat feet;fallen constitutes riot, or rebellion;
What Is Not Covered? 3-3
c) your engaging in an illegal occupation; Arrangement. This exclusion applies to all
d) Services received at military or expenses for prenatal, intra-partal, and post-
government facilities; or partal Maternity/Obstetrical Care, and Health
e) Services received to treat a Condition Care Services rendered to the Covered Person
arising out of your service in the armed acting as a Gestational Surrogate.
forces, reserves and/or National Guard; For the definition of Gestational Surrogate and
Gestational Surrogacy Contract see the
f) Services that are not patient-specific, as Definitions section of this Benefit Booklet.
determined solely by us.
9. Health Care Services rendered because Oral Surgery except as provided under the
'What Is Covered?"section.
they were ordered by a court, unless such
Services are Covered Services under this Orthomolecular Therapy including nutrients,
Benefit Booklet; and vitamins, and food supplements.
10. any Health Care Services rendered by or Oversight of a medical laboratory by a
through a medical or dental department Physician or other health care Provider.
maintained by or on behalf of an employer, "Oversight"as used in this exclusion shall,
mutual association, labor union,trust, or include, but is not limited to,the oversight of:
similar person or group; or 1. the laboratory to assure timeliness,
11. Health Care Services that are not direct, reliability, and/or usefulness of test results;
hands-on, and patient specific, including, but 2. the calibration of laboratory machines or
not limited to the oversight of a medical testing of laboratory equipment;
laboratory to assure timeliness, reliability,
and/or usefulness of test results, or the 3. the preparation, review or updating of any
oversight of the calibration of laboratory protocol or procedure created or reviewed
machines,equipment,or laboratory by a Physician or other health care Provider
technicians. in connection with the operation of the
laboratory; and
Genetic screening, including the evaluation of
genes to determine if you are a carrier of an 4. laboratory equipment or laboratory
abnormal gene that puts you at risk for a personnel for any reason.
Condition, except as provided under the Personal Comfort, Hygiene or Convenience
Preventive Health Services category of the Items and Services deemed to be not Medically
'What Is Covered?"section. Necessary and not directly related to your
Hearing Aids(external or implantable)and treatment including, but not limited to:
Services related to the fitting or provision of 1. beauty and barber services;
hearing aids, including tinnitus maskers, 2. clothing including support hose;
batteries,and cost of repair. 3. radio and television;
Immunizations except those covered under the 4. guest meals and accommodations;
Preventive Health Services category of the 5. telephone charges;
'What Is Covered?"section. 6. take-home supplies;
Maternity Services rendered to a Covered 7. travel expenses(other than Medically
Person who becomes pregnant as a Gestational Necessary Ambulance Services);
Surrogate under the terms of, and in accordance g. motel/hotel accommodations;
with, a Gestational Surrogacy Contract or
What Is Not Covered? 3-4
9. air conditioners,furnaces, air filters, air or conditioning programs such as athletic training,
water purification systems,water softening bodybuilding, exercise,fitness,flexibility, and
systems, humidifiers, dehumidifiers,vacuum diversion or general motivation.
cleaners or any other similar equipment and
devices used for environmental control or to Training and Educational Programs, or
enhance an environmental setting; materials, including, but not limited to programs
or materials for pain management and
10. hot tubs, Jacuzzis, heated spas, pools, or vocational rehabilitation, except as provided
memberships to health clubs; under the Diabetes Outpatient Self Management
11. heating pads, hot water bottles,or ice packs; category of the"What Is Covered?"section.
12. physical fitness equipment;
Travel or vacation expenses even if prescribed
13. hand rails and grab bars; and or ordered by a Provider.
14. Massages except as covered in the"What Is
Volunteer Services or Services which would
Covered?"section of this Booklet.
normally be provided free of charge and any
Private Duty Nursing Care rendered at any charges associated with Deductible,
location. Coinsurance, or Copayment(if applicable)
Rehabilitative Therapies provided on an requirements which are waived by a health care
inpatient or outpatient basis, except as provided Provider.
in the Hospital, Skilled Nursing Facility, Home Weight Control Services including any service
Health Care,and Outpatient Cardiac, to lose, gain, or maintain weight, including
Occupational, Physical, Speech, Massage without limitation: any weight control/loss
Therapies and Spinal Manipulations categories program;appetite suppressants;dietary
of the"What Is Covered?"section. regimens;food or food supplements; exercise
Rehabilitative Therapies provided for the programs; equipment; whether or not it is part of
purpose of maintaining rather than improving a treatment plan for a Condition.
your Condition are also excluded.
Wigs and/or cranial prosthesis.
Reversal of Voluntary, Surgically-Induced
Sterility including the reversal of tubal ligations
and vasectomies.
Sexual Reassignment,or Modification
Services including, but not limited to, any Health
Care Services related to such treatment,such
as psychiatric Services.
Smoking Cessation Programs including any
service to eliminate or reduce the dependency
on,or addiction to,tobacco, including but not
limited to nicotine withdrawal programs and
nicotine products(e.g., gum,transdermal
patches, etc.).
Sports-Related devices and services used to
affect performance primarily in sports-related
activities;all expenses related to physical
What Is Not Covered? 3-5
Section 4: Medical Necessity
In order for Health Care Services to be covered 1. staying in the Hospital because
under this Booklet, such Services must meet all arrangements for discharge have not been
of the requirements to be a Covered Service, completed;
including being Medically Necessary, as defined 2. use of laboratory, x-ray, or other diagnostic
by this Benefit Booklet. testing that has no clear indication, or is not
It is important to remember that any review of expected to alter your treatment;
Medical Necessity we undertake is solely for the 3. staying in the Hospital because supervision
purposes of determining coverage, benefits,or in the home, or care in the home, is not
payment under the terms of this Booklet and not available or inconvenient;or being
for the purpose of recommending or providing hospitalized for any Service which could
� medical care. In conducting a review of Medical have been provided adequately in an
Necessity, BCBSF may review specific medical
facts or information pertaining to you. Any such alternate setting(e.g., Hospital outpatient
review, however, is strictly for the purpose of department); or
determining whether a Health Care Service 4. inpatient admissions to a Hospital, Skilled
provided or proposed meets the definition of Nursing Facility, or any other facility for the
Medical Necessity in this Booklet. In applying purpose of Custodial Care, convalescent
the definition of Medical Necessity in this care, or any other Service primarily for the
Booklet to a specific Health Care Service, convenience of the patient or his or her
coverage and payment guidelines then in effect family members or a Provider.
may be applied by BCBSF. Note: Whether or not a Health Care Service
All decisions that require or pertain to is specifically listed as an exclusion,the fact
independent professional medical/clinical that a Provider may prescribe, recommend,
judgement or training, or the need for medical approve, or furnish a Health Care Service
services, are solely your responsibility and that does not mean that the Service is Medically
of your treating Physicians and health care Necessary(as defined by this Benefit
Providers. You and your Physicians are Booklet)or a Covered Service. Please refer
responsible for deciding what medical care to the"Definitions" section for the
should be rendered or received and when that definitions of"Medically Necessary"or
care should be provided. Monroe County BOCC "Medical Necessity".
is ultimately responsible for determining whether
expenses incurred for medical care are covered
under this Booklet. In making coverage
decisions, neither BCBSF nor Monroe County
BOCC will be deemed to participate in or
override your decisions concerning your health
or the medical decisions of your health care
Providers.
Examples of hospitalization and other Health
Care Services that are not Medically Necessary
include, but are not limited to:
Medical Necessity 4-1
Section 5: Understanding Your Share of Health Care
Expenses
This section explains what your share of the Benefits for the specific Covered Services which
health care expenses will be for Covered are subject to a Copayment. Listed below is a
Services you receive. In addition to the brief description of some of the Copayment
information explained in this section, it is requirements that may apply to your plan. If the
important that you refer to your Schedule of Allowed Amount or the Provider's actual charge
Benefits to determine your share of the cost with for a Covered Service rendered is less than the
regard to Covered Services. Copayment amount, you must pay the lesser of
the Allowed Amount or the Provider's actual
Deductible Requirement charge for the Covered Service.
Individual Deductible 1. Office Services Copayment:
This amount,when applicable, must be satisfied If your plan is a Copayment plan, the
by you and each of your Covered Dependents Copayment for Covered Services rendered
each Benefit Period, before any payment will be in the office(when applicable)must be
made by the Group Health Plan. Only those satisfied by you,for each office Service
before any payment will be made. The
charges indicated on claims received for office Services Copayment applies
Covered Services will be credited toward the regardless of the reason for the office visit
individual Deductible and only up to the and applies to all Covered Services
applicable Allowed Amount. Please see your rendered in the office,with the exception of
Schedule of Benefits for more information. Durable Medical Equipment, Medical
Family Deductible Pharmacy, Prosthetics, and Orthotics.
If your plan includes a family Deductible, after Generally, if more than one Covered Service
the family Deductible has been met by your that is subject to a Copayment is rendered
family, neither you nor your Covered during the same office visit, you will be
Dependents will have any additional Deductible responsible for a single Copayment which
responsibility for the remainder of that Benefit will not exceed the highest Copayment
Period. The maximum amount that any one specified in the Schedule of Benefits for the
Covered Person in your family can contribute particular Health Care Services rendered.
toward the family Deductible, if applicable, is the 2. Inpatient Facility Copayment:
amount applied toward the individual Deductible.
Please see your Schedule of Benefits for more The inpatient facility Copayment must be
satisfied by you,for each inpatient
information.
admission to a Hospital, Psychiatric Facility,
Copayment Requirements or Substance Abuse Facility, before any
payment will be made for any claim for
Covered Services rendered by certain Providers inpatient Covered Services. The inpatient
or at certain locations or settings will be subject facility Copayment applies regardless of the
to a Copayment requirement. This is the dollar reason for the admission, and applies to all
amount you have to pay when you receive these inpatient admissions to a Hospital,
Services. Please refer to your Schedule of Psychiatric Facility or Substance Abuse
Understanding Your Share of Health Care Expenses 5-1
Facility in or outside the state of Florida. Hospital Per Admission Deductible
Additionally,you will be responsible for out-
of-pocket expenses for Covered Services The Hospital Per Admission Deductible(PAD)
provided by Physicians and other health must be satisfied by each Covered Plan
care professionals for inpatient admissions. Participant,for each Hospital admission, before
any payment will be made for any claim for
Note: Inpatient facility Copayments may inpatient Health Care Services. The Hospital
vary depending on the facility chosen. per Admission Deductible applies regardless of
(Please see the Schedule of Benefits for the reason for the admission, is in addition to the
more information).
Deductible requirement, and applies to all
3. Outpatient Facility Copayment: Hospital admissions in or outside the state of
The outpatient facility Copayment must be Florida.
satisfied by you,for each outpatient visit to a Emergency Room Per Visit
Hospital,Ambulatory Surgical Center, Deductible
Independent Diagnostic Testing Facility,
Psychiatric Facility or Substance Abuse The Emergency Room Per Visit Deductible
Facility, before any payment will be made for (PVD)is set forth in the Schedule of Benefits.
any claim for outpatient Covered Services. The Emergency Room Per Visit Deductible
The Outpatient Facility Copayment applies applies regardless of the reason for the visit, is
regardless of the reason for the visit,and in addition to the Deductible, and applies to
applies to all outpatient visits to a Hospital, emergency room services in or outside the state
Psychiatric Facility or Substance Abuse of Florida. The Emergency Room Per Visit
Facility in or outside the state of Florida. Deductible must be satisfied by each Covered
Additionally, you will be responsible for out- Plan Participant for each visit. If the Covered
of-pocket expenses for Covered Services Plan Participant is admitted to the Hospital at the
provided by Physician and other healthcare time of the emergency room visit,the
professionals. Emergency Room Per Visit Deductible will be
Note: Outpatient facility Copayments may waived.
vary depending on the facility chosen. Coinsurance Requirements
(Please see the Schedule of Benefits for
more information). All applicable Deductible or Copayment amounts
must be satisfied before any portion of the
4. Emergency Room Facility Copayment: Allowed Amount will be paid for Covered
The emergency room facility Copayment Services. For Services that are subject to
applies regardless of the reason for the visit, Coinsurance,the Coinsurance percentage of the
is in addition to the applicable Coinsurance applicable Allowed Amount you are responsible
amount, and applies to emergency room for is listed in the Schedule of Benefits.
facility Services in or outside the state of
Florida. The emergency room facility Out-of-Pocket Maximums
Copayment must be satisfied by you for
each visit. If you are admitted to the Individual out-of-pocket maximum
Hospital as an inpatient at the time of the Once you have reached the individual out-of-
emergency room visit,the emergency room pocket maximum amount listed in the Schedule
facility Copayment will be waived, but you of Benefits, you will have no additional out-of-
will still be responsible for the inpatient pocket responsibility for the remainder of that
facility Copayment. Benefit Period and we will pay 100 percent of
Understanding Your Share of Health Care Expenses 5-2
the Allowed Amount for Covered Services in effect immediately preceding the Effective
rendered during the remainder of that Benefit Date of the coverage provided under this Benefit
Period. Booklet. This provision is only applicable for you
Family out-of-pocket maximum during the initial Benefit Period of coverage
under this Benefit Booklet and the following
If your plan includes a family out-of-pocket rules apply:
maximum,once your family has reached the
1. Prior Coverage Credit for Deductible:
family out-of-pocket maximum amount listed in
the Schedule of Benefits, neither you nor your For the initial Benefit Period of coverage
covered family members will have any additional under this Benefit Booklet only,charges
out-of-pocket responsibility for the remainder of credited towards your Deductible
that Benefit Period and we will pay 100 percent requirement under the prior policy or plan,
of the Allowed Amount for Covered Services for Services rendered during the 90-day
rendered during the remainder of that Benefit period immediately preceding the Effective
Period. The maximum amount any one Covered Date of the coverage under this Benefit
Person in your family can contribute toward the Booklet,will be credited to the Deductible
family out-of-pocket maximum, if applicable, is requirement under this Booklet.
the amount applied toward the individual out-of- 2. Prior Coverage Credit for Coinsurance:
pocket maximum. Please see your Schedule of
Benefits for more information. Charges credited by Monroe County
BOCC's prior policy or plan,towards your
Note: Any applicable Copayments and Coinsurance Maximum,for Services
Coinsurance amounts will accumulate toward rendered during the 90-day period
the out-of-pocket maximums. Any benefit immediately preceding the Effective Date of
penalty reductions, Deductible, PAD, PVD, non- coverage under this Benefit Booklet, will be
covered charges or any charges in excess of the
credited to your out-of-pocket maximum
Allowed Amount will not accumulate toward the
under this Booklet.
out-of-pocket maximums. If the Group has
purchased Prescription Drug coverage, any 3. Prior coverage credit towards the Deductible
applicable Cost Share under the Prescription or out-of-pocket maximums will only be
Drug coverage, will not apply to the Deductible given for Health Care Services which would
or the out-of-pocket maximums under this have been Covered Services under this
Booklet. Booklet.
4. Prior coverage credit under this Booklet only
Prior Coverage Credit applies at the initial enrollment of the entire
You will be given credit for the satisfaction or Group. You and/or Monroe County BOCC
partial satisfaction of any Deductible and are responsible for providing BCBSF with
Coinsurance maximums met by you under a any information necessary for BCBSF to
prior group insurance, blanket insurance, or apply this prior coverage credit.
franchise insurance or group Health
Maintenance Organization (HMO)policy or plan Benefit Maximum Carryover
maintained by Monroe County BOCC if the
coverage provided hereunder replaces such a If immediately before the Effective Date of the
policy or plan.This provision only applies if the coverage under this Benefit Booklet, you were
prior group insurance, blanket insurance, covered under a prior Monroe County BOCC
franchise insurance, HMO or plan coverage was group plan insured or administered by BCBSF,
Understanding Your Share of Health Care Expenses 5-3
l
amounts applied to your benefit maximums
under the prior group plan,will be applied
toward your benefit under this Booklet.
Additional Expenses You Must Pay
In addition to your share of the expenses
described above, you are also responsible for:
1. any applicable Copayments;
2. expenses incurred for non-covered
Services;
3. charges in excess of any maximum benefit
limitation listed in the Schedule of Benefits
(e.g.,the Benefit Period maximums);
4. charges in excess of the Allowed Amount for
Covered Services rendered by Providers
who have not agreed to accept the Allowed
Amount as payment in full;
5. any benefit reductions;
6. payment of expenses for claims denied
because we did not receive information
requested from you regarding whether or not
you have other coverage and the details of
such coverage; and
7. charges for Health Care Services which are
excluded.
Additionally, you are responsible for any
contribution amount required by Monroe County
BOCC.
How Benefit Maximums Will Be
Credited
Only amounts actually paid for Covered
Services will be credited towards any applicable
benefit maximums. The amounts paid which are
credited towards your benefit maximums will be
based on the Allowed Amount for the Covered
Services provided.
Understanding Your Share of Health Care Expenses 5-4
Section 6: Physicians, Hospitals and Other Provider
Options
Introduction continuing a relationship with a Family Physician
It is important for you to understand how the allows the physician to become knowledgeable
Provider you select and the setting in which you about you and your family's health history. A
receive Health Care Services affects how much Family Physician can help you determine when
you are responsible for paying under this you need to visit a specialist and also help you
Booklet. This section, along with the Schedule find one based on their knowledge of you and
of Benefits,describes the health care Provider your specific healthcare needs. Types of Family
options available to you and the payment rules Physicians are Family Practitioners, General
for Services you receive. Practitioners, Internal Medicine doctors and
Pediatricians. Additionally,care rendered by
As used throughout this section"out-of-pocket Family Physicians usually results in lower out-of-
expenses"or"out-of-pocket'refers to the pocket expenses for you. Whether you select a
amounts you are required to pay including any Family Physician or another type of Physician to
applicable Copayments,the Deductible and/or render Health Care Services, please remember
Coinsurance amounts for Covered Services. that using In-Network Providers may result in
lower out-of-pocket expenses for you. You
You are entitled to preferred provider type should always determine whether a Provider is
benefits when you receive Covered Services In-Network or Out-of-Network prior to receiving
from In-Network Providers. You are entitled to Services to determine the amount you are
traditional program type benefits at the point of responsible for paying out-of-pocket.
service when you receive Covered Services
from Traditional Program Providers or BlueCard Location of Service
(Out-of-State)Traditional Program Providers, in
conformity with Section 7: BlueCard (Out-of- In addition to the participation status of the
State)Program. Provider,the location or setting where you
receive Services can affect the amount you pay.
Provider Participation Status For example,the amount you are responsible for
paying out-of-pocket will vary whether you
With BlueCiptions, you may choose to receive receive Services in a Hospital, a Provider's
Services from any Provider. However, you may office, or an Ambulatory Surgical Center.
be able to lower the amount you have to pay for Please refer to your Schedule of Benefits for
Covered Services by receiving care from an In- specific information regarding your out-of-pocket
Network Provider. Although you have the option expenses for such situations. After you and
to select any Provider you choose, you are your Physician have determined the plan of
encouraged to select and develop a relationship treatment most appropriate for your care, you
with an In-Network Family Physician. There are should refer to the'What Is Covered?"section
several advantages to selecting a Family and your Schedule of Benefits to find out if the
Physician. Family Physicians are trained to specific Health Care Services are covered and
provide a broad range of medical care and can how much you will have to pay. You should also
be a valuable resource to coordinate your consult with your Physician to determine the
overall healthcare needs. Developing and most appropriate setting based on your health
care and financial needs.
Physicians,Hospitals and Other Provider Options 6-1
To verify if a Provider is In-Network benefit plan,the Provider is considered Out-of-
for your plan you can: Network.
1. If in Florida, review your current BlueOptions
Provider Directory;
2. If in Florida, access the BlueOptions
Provider directory at BCBSF's web-site at
www.floridablue.com; and/or
3. If outside of Florida, access the on-line
BlueCard Doctor and Hospital Finder at
www.floridablue.com; and/or
4. Call the customer service phone number in
this Booklet or on your Identification Card to
search for PPO providers.
Please remember that changes to Provider
network participation can occur at any time.
Consequently, it is your responsibility to
determine whether a specific Provider is In-
Network at the time you receive Covered
Services.
In-Network Providers
When you use In-Network Providers, your out-
of-pocket expenses for Covered Services may
be lower. Payment will be based on the Allowed
Amount and your share of the cost will be at the
In-Network benefit level listed in the Schedule of
Benefits.
Out-of-Network Providers
When you use Out-of-Network Providers your
out-of-pocket expenses for Covered Services
will be higher. We will base our payment on the
Allowed Amount at the Coinsurance percentage
listed in the Schedule of Benefits. Further, if the
Out-of-Network Provider is a Traditional
Program Provider or a BlueCard (Out-of-State)
Traditional Program Provider,our payment to
such Provider may be under the terms of that
Provider's contract. If your Schedule of Benefits
and BlueOptions Provider directory do not
include a Provider as In-Network under your
Physicians,Hospitals and Other Provider Options 6-2
In-Network Out-of-Network
What expenses • Any applicable Copayments, Deductible(s)and/or Coinsurance requirements;
are you • Expenses for Services which are not covered;
responsible for • Expenses for Services in excess of any benefit maximum limitations;
paying? • Expenses for claims denied because we did not receive information
requested from you regarding whether or not you have other coverage and
the details of such coverage; and
• Expenses for Services which are excluded.
Who is • The Provider will file the claim ' You are responsible for filing the
responsible for for you and payment will be claim and payment will be made
filing your made directly to the Provider. directly to the Covered Plan
claims? Participant. If you receive Services
from a Provider who participates in
our Traditional Program or is a
BlueCard (Out-of-State)Traditional
Program Provider, the Provider will
file the claim for you. In those
instances payment will be made
directly to the Provider.
Can you be billed • NO. You are protected from • YES. You are responsible for paying
the difference being billed for the difference in the difference between what we pay
between what the the Allowed Amount and the and the Provider's charge. However,
Provider is paid Provider's charge when you use if you receive Services from a
and the Provider's In-Network Providers. The Provider who participates in our
charge? Provider will accept the Allowed Traditional Program,the Provider will
Amount as payment in full for accept our Allowed Amount as
Covered Services except as payment in full for Covered Services
otherwise permitted under the since such Traditional Program
terms of the Provider's contract Providers have agreed not to bill you
and this Booklet. for the difference. Further, under the
BlueCard(Out-of-State)Program,
when you receive Covered Services
from a BlueCard(Out-of-State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In-Network or Out-of-Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians,Hospitals and Other Provider Options 6-3
Physicians admits to by contacting the Physician's office.
This will provide you with information that will
When you receive Covered Services from a help you determine a portion of what your out-of-
Physician you will be responsible for a pocket costs may be in the event you are
Copayment and/or the Deductible and the hospitalized.
applicable Coinsurance. Several factors will Refer to your Schedule of Benefits to determine
determine your out-of-pocket expenses including
the applicable out-of-pocket expenses you are
your Schedule of Benefits,whether the
responsible for paying for Hospital Services.
Physician is In-Network or Out-of-Network,the
location of service, the type of Service rendered, Specialty Pharmacy
and the Physician's specialty.
Remember that the location or setting where a Certain medications, such as injectable, oral,
Service is rendered can affect the amount you inhaled and infused therapies used to treat
are responsible for paying out-of-pocket. After complex medical Conditions are typically more
you and your Physician have determined the difficult to maintain, administer and monitor
plan of treatment most appropriate for your care, when compared to traditional Drugs. Specialty
you should refer to the Schedule of Benefits and Drugs may require frequent dosage
consult with your Physician to determine the adjustments, special storage and handling and
most appropriate setting based on your health may not be readily available at local pharmacies
care and financial needs. or routinely stocked by Physicians'offices,
Refer to your Schedule of Benefits to determine mostly due to the high cost and complex
the applicable Copayments, Coinsurance handling they require.
percentage and/or Deductible amount you are Using the Specialty Pharmacy to provide these
responsible for paying for Physician Services. Specialty Drugs should lower the amount you
have to pay for these medications,while helping
Hospitals to preserve your benefits.
Each time you receive inpatient or outpatient Other Providers
Covered Services at a Hospital, in addition to
any out-of-pocket expenses related to Physician With BlueOptions you have access to other
Services, you will be responsible for out-of- Providers in addition to the ones previously
pocket expenses related to Hospital Services. described in this section. Other Providers
In-Network Hospitals have been divided into two include facilities that provide alternative
groups that are referred to as"options"on the outpatient settings or other persons and entities
Schedule of Benefits. The amount you are that specialize in a specific Service(s). While
responsible for paying out-of-pocket is different these Providers may be recognized for payment,
for each of these options. Remember that there they may not be included as In-Network
are also different out-of-pocket expenses for Providers for your plan. Additionally, all of the
Out-of-Network Hospitals. Services that are within the scope of certain
Providers' licenses may not be Covered
Since not all Physicians admit patients to every Services under this Booklet. Please refer to the
Hospital, it is important when choosing a 'What Is Covered?"and"What Is Not Covered?"
Physician that you determine the Hospitals sections of this Booklet and your Schedule of
where your Physician has admitting privileges. Benefits to determine your out-of-pocket
You can find out what Hospitals your Physician
Physicians,Hospitals and Other Provider Options 6-4
expenses for Covered Services rendered by 4)is a BlueCard(Out-of-State)PPO Program
these Providers. Provider; 5)is a BlueCard(Out-of-State)
You may be able to receive certain outpatient Traditional Program Provider;6)is a licensed
Services at a location other than a Hospital. The Hospital, Physician, or dentist and the benefits
amount you are responsible for paying for which have been assigned are for care provided
Services rendered at some alternative facilities pursuant to section 395.1041, Florida Statutes;
is generally less than if you had received those or 7)is an Ambulance Provider that provides
same Services at a Hospital. transportation for Services from the location
where an "emergency medical condition",
Remember that the location of service can defined in section 395.002(8)Florida Statutes,
impact the amount you are responsible for first occurred to a Hospital, and the benefits
paying out-of-pocket. After you and your which have been assigned are for transportation
Physician have determined the plan of treatment to care provided pursuant to section 395.1041,
most appropriate for your care, you should refer Florida Statutes. A written attestation of the
to the Schedule of Benefits and consult with assignment of benefits may be required.
your Physician to determine the most
appropriate setting based on your health care
and financial needs. When Services are
rendered at an outpatient facility other than a
Hospital there may be an out-of-pocket expense
for the facility Provider as well as an out-of-
pocket expense for other types of Providers.
Assignment of Benefits to Providers
Except as set forth in the last paragraph of this
section, any of the following assignments, or
attempted assignments, by you to any Provider
will not be honored:
• an assignment of the benefits due to you for
Covered Services under this Benefit
Booklet;
• an assignment of your right to receive
payments for Covered Services under this
Benefit Booklet; or
• an assignment of a claim for damage
resulting from a breach,or an alleged
breach of the terms of this Benefit Booklet.
j We specifically reserve the right to honor an
assignment of benefits or payment by you to a
Provider who: 1)is In-Network under your plan
of coverage; 2)is a NetworkBlue Provider even
if that Provider is not in the panel for your plan of
coverage; 3) is a Traditional Program Provider;
Physicians,Hospitals and Other Provider Options 6-5
Section 7: BlueCard® (Out-of-State) Program
Out-of-Area Services • The negotiated price that the Host Blue
makes available to us.
We have a variety of relationships with other
Blue Cross and/or Blue Shield Licensees Often,this"negotiated price'will be a simple
referred to generally as"Inter-Plan Programs". discount that reflects an actual price that the Host
Whenever you obtain Health Care Services Blue pays to your health care Provider.
outside of our service area,the claims for these Sometimes, it is an estimated price that takes into
Services may be processed through one of account special arrangements with your health
these Inter-Plan Programs,which include the care Provider or Provider group that may include
BlueCard Program and may include negotiated types of settlements, incentive payments, and/or
National Account arrangements available other credits or charges. Occasionally, it may be
between us and other Blue Cross and Blue an average price, based on a discount that
Shield Licensees. results in expected average savings for similar
Typically,when accessing care outside our types of health care Providers after taking into
service area, you will obtain care from health account the same types of transactions as with
care Providers that have a contractual an estimated price.
agreement(i.e., are"participating providers") Estimated pricing and average pricing, going
with the local Blue Cross and/or Blue Shield forward, also take into account adjustments to
Licensee in that other geographic area("Host correct for over-or underestimation of
Blue"). In some instances, you may obtain care modifications of past pricing for the types of
from non-participating health care Providers. transaction modifications noted above. However,
Our payment practices in both instances are such adjustments will not affect the price we use
described below. for your claim because they will not be applied
retroactively to claims already paid.
BlueCard Program Laws in a small number of states may require the
Under the BlueCard Program,when you Host Blue to add a surcharge to your calculation.
access Covered Services within the geographic If any state laws mandate other liability
area served by a Host Blue,we will remain calculation methods, including a surcharge,we
responsible for fulfilling our contractual would then calculate your liability for any Covered
obligations. However,the Host Blue is Services according to applicable law.
responsible for contracting with and generally
handling all interactions with its participating Out-of-Network Providers Outside Our
health care Providers. Service Area
Whenever you access Covered Services Your Liability Calculation
outside our service area and the claim is When Covered Services are provided outside of
processed through the BlueCard Program,the our service area by non-participating health care
amount you pay for Covered Services is Providers,the payment will be based on the
calculated based on the lower of: Allowed Amount as defined in the Benefit
• The billed covered charges for your Booklet.
Covered Services; or
BlueCard(Out-of-State)Program 7-1
Section 8: Blueprint for Health Programs
Introduction Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility(as applicable)if we
BCBSF has established(and from time to time have been notified of your admission. For an
establishes)various customer-focused health admission outside of Florida,you or the
education and information programs as well as Hospital, Psychiatric Facility, Substance Abuse
benefit utilization management and utilization
review programs. Under the terms of the ASO Facility or Skilled Nursing Facility(as applicable)
Agreement between BCBSF and Monroe should notify us of the admission. Making sure
County BOCC, BCBSF has agreed to make that we are notified of your admission will enable
these programs available to you.These us to provide you information about the Blueprint
programs,collectively called the Blueprint for for Health Programs available to you. You or
Health Programs, are designed to 1)provide you the Hospital, Psychiatric Facility, Substance
with information that will help you make more Abuse Facility or Skilled Nursing Facility(as
informed decisions about your health,2)help applicable)may notify us of your admission by
facilitate the management and review of calling the toll free customer service number on
coverage and benefits provided under this your ID card.
Booklet and 3)present opportunities, as
explained below,to mutually agree upon Out-of-Network
alternative benefits or payment alternatives for
cost-effective medically appropriate Health Care For admissions to an Out-of-Network Hospital,
Services. Some BluePrint For Health Psychiatric Facility, Substance Abuse Facility or
Programs may not be available outside the Skilled Nursing Facility, you or the Hospital,
state of Florida. Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility should notify BCBSF of
Admission Notification the admission. Notifying BCBSF of your
admission will enable BCBSF to provide you
The admission notification requirements vary information about the Blueprint for Health
depending on whether you are admitted to a Programs available to you. You or the Hospital
Hospital, Psychiatric Facility, Substance Abuse may notify BCBSF of your admission by calling
Facility or Skilled Nursing Facility which is In- the toll-free customer service number on your ID
Network or Out-of-Network. card.
In-Network Inpatient Facility Program
Under the admission notification requirement, Under the inpatient facility program,we may
we must be notified of all inpatient admissions review Hospital stays, Hospice, Inpatient
(i.e., elective, planned, urgent or emergency)to Rehabilitation, LTAC and Skilled Nursing Facility
In-Network Hospitals, Psychiatric Facilities, (SNF)Services, and other Health Care Services
Substance Abuse Facilities or Skilled Nursing rendered during the course of an inpatient stay
Facilities. While it is the sole responsibility of or treatment program. We may conduct this
the In-Network Provider located in Florida to review while you are inpatient, after your
comply with our admission notification discharge, or as part of a review of an episode
requirements, you should ask the Hospital, of care when you are transferred from one level
Blueprint for Health Programs 8-1
P
of inpatient care to another for ongoing required under the terms of their agreement
treatment. The review is conducted solely to with us;or
determine whether we should provide coverage 2 we perform a focused review under the
and/or payment for a particular admission or
focused utilization management program
Health Care Services rendered during that and we determine that a Health Care
admission. Using our established criteria then in Service is not Medically Necessary in
effect, a concurrent review of the inpatient stay accordance with our Medical Necessity
may occur at regular intervals, including in
criteria or inconsistent with our benefit
advance of a transfer from one inpatient facility guidelines then in effect unless the following
to another. We will provide notification to your
exception applies.
Physician when inpatient coverage criteria are
no longer met. In administering the inpatient Exception for Certain NetworkBlue Physicians
facility program,we may review specific medical Certain NetworkBlue Physicians licensed as
facts or information and assess,among other Doctors of Medicine(M.D.)or Doctors of
things,the appropriateness of the Services Osteopathy(D.O.)only may bill you for Services
being rendered, health care setting and/or the determined to be not Medically Necessary by
level of care of an inpatient admission or other BCBSF under this focused utilization
health care treatment program. Any such
management program if, before you receive the
reviews by us, and any reviews or assessments Service:
of specific medical facts or information which we
conduct, are solely for purposes of making a. they give you a written estimate of your
coverage or payment decisions under this financial obligation for the Service;
Benefit Booklet and not for the purpose of b. they specifically identify the proposed
recommending or providing medical care. Service that BCBSF has determined not to
Provider Focused Utilization be Medically Necessary; and
Management Program c. you agree to assume financial responsibility
for such Service.
Certain NetworkBlue Providers have agreed to
participate in our focused utilization Prior Coverage Authorization/Pre-
management program. This pre-service review Service Notification Programs
program is intended to promote the efficient
delivery of medically appropriate Health Care It is important for you to understand our prior
Services by NetworkBlue Providers. Under this coverage authorization programs and how the
program we may perform focused prospective Provider you select and the type of Service you
reviews of all or specific Health Care Services receive affects these requirements and
proposed for you. In order to perform the ultimately how much you are responsible for
review,we may require the Provider to submit to paying under this Benefit Booklet.
us specific medical information relating to Health You or your Provider will be required to obtain
Care Services proposed for you. These prior coverage authorization from us for:
NetworkBlue Providers have agreed not to bill,
or collect, any payment whatsoever from you or 1. advanced diagnostic imaging Services,
us,or any other person or entity, with respect to such as CT scans, MRIs, MRA and nuclear
a specific Health Care Service if: imaging;
1. they fail to submit the Health Care Service
for a focused prospective review when
Blueprint for Health Programs 8-2
1
2. Autism Spectrum Disorder; Mental customer service phone number on the back
Health; and Substance Dependency of your ID Card.
Services; and 2. In the case of Autism Spectrum Disorder,
3. other Health Care Services that are or may Mental Health, and Substance
become subject to a prior coverage Dependency Services under a prior
authorization program or a pre-service coverage authorization or pre-service
notification program as defined and notification program, it is your sole
administered by us. responsibility to comply with our prior
Prior coverage authorization requirements vary, coverage authorization or pre-service
depending on whether Services are rendered by notification requirements when rendered or
an In-Network Provider or an Out-of-Network referred by an Out-of-Network Provider,
Provider, as described below: before the Services are provided. Failure
to obtain prior coverage authorization
In-Network Providers will result in denial of coverage for such
Services.
It is the In-Network Provider's sole responsibility
to comply with our prior coverage authorization 3. In the case of other Health Care Services
requirements,and therefore you will not be under a prior coverage authorization or pre-
responsible for any benefit reductions if prior service notification program, it is your sole
coverage authorization is not obtained before responsibility to comply with our prior
Medically Necessary Services are rendered. coverage authorization or pre-service
Once we have received the necessary medical notification requirements when rendered or
documentation from the Provider,we will review referred by an Out-of-Network Provider,
the information and make a prior coverage before the Services are provided. Failure
authorization decision, based on our established to obtain prior coverage authorization or
criteria then in effect. The Provider will be provide pre-service notification may
notified of the prior coverage authorization result in denial of the claim or application
decision. of a financial penalty assessed at the
Out-of-Network Providers
time the claim is presented for payment
to us. The penalty applied will be the lesser
P Y PP
1. In the case of advanced diagnostic of$500 or 20% of the total Allowed Amount
imaging Services such as CT scans, MRIs,
MRA and nuclear imaging, it is your sole of the claim. The decision to apply a penalty
or den the claim will be made uniform) and
responsibility to comply with our prior y y
coverage authorization requirements when will be identified in the notice describing the
prior coverage authorization and pre-service
rendered or referred by an Out-of-Network
Provider before the advanced diagnostic notification programs.
imaging Services are provided. Your Once the necessary medical documentation has
failure to obtain prior coverage been received from you and/or the Out-of-
authorization will result in denial of Network Provider, BCBSF or a designated
coverage for such Services. vendor,will review the information and make a
For additional details on how to obtain prior prior coverage authorization decision, based on
coverage authorization for advanced our established criteria then in effect. You will
diagnostic imaging Services, please call the be notified of the prior coverage authorization
decision.
Blueprint for Health Programs 8-3
BCBSF will provide you information for any Out- made available on a case-by-case basis when
of-Network Health Care Service subject to a you meet BCBSF's case management criteria
prior coverage authorization or pre-service then in effect. Such alternative benefits or
notification program, including how you can payments, if any,will be made available in
obtain prior coverage authorization and/or accordance with a treatment plan with which
provide the pre-service notification for such you, or your representative, and your Physician
Service not already listed here. This information agree to in writing. In addition, Monroe County
will be provided to you upon enrollment, or at BOCC will be required to specifically agree to
least 30 days prior to such Out-of-Network such treatment plan and the alternative benefits
Services becoming subject to a prior coverage or payment.
authorization or pre-service notification program. The fact that certain Health Care Services under
See the"Claims Processing"section for the personal case management program have
information on what you can do if prior coverage been provided or payment has been made in no
authorization is denied. way obligates BCBSF, Monroe County BOCC,
Note: Prior coverage authorization is not or the Group Health Plan to continue to provide
required when Covered Services are provided or pay for the same or similar Services. Nothing
for the treatment of an Emergency Medical contained in this section shall be deemed a
Condition. waiver of Monroe County BOCC's right to
enforce this Booklet in strict accordance with its
Member Focused Programs terms. The terms of this Booklet will continue to
apply, except as specifically modified in writing
The Blueprint for Health Programs may include
voluntary programs for certain members. These in accordance with the personal case
programs may address health promotion, management program rules then in effect.
prevention and early detection of disease, Health Information, Promotion, Prevention
chronic illness management programs, case and Illness Management Programs
management programs and other member These Blueprint for Health Programs may
focused programs. include health information that supports health
care education and choices for healthcare
Personal Case Management Program issues. These programs focus on keeping you
The personal case management program well, help to identify early preventive measures
focuses on members who suffer from a of treatment and help covered individuals with
catastrophic illness or injury. In the event you chronic problems to enjoy lives that are as
have a catastrophic or chronic Condition,we productive and healthy as possible. These
may, in BCBSF's sole discretion, assign a programs may include prenatal educational
Personal Case Manager to you to help programs and illness management programs for
coordinate coverage, benefits, or payment for Conditions such as diabetes, cancer and heart
Health Care Services you receive. Your disease. These programs are voluntary and are
participation in this program is completely designed to enhance your ability to make
voluntary. informed choices and decisions for your unique
health care needs. You may call the toll free
Under the personal case management program, customer service number on your ID card for
you may be offered alternative benefits or more information. Your participation in this
payment for cost-effective Health Care Services. program is completely voluntary.
These alternative benefits or payments may be
Blueprint for Health Programs 8-4
IMPORTANT INFORMATION RELATING TO
BCBSF'S BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain to
independent professional medical/clinical
judgment or training,or the need for medical
services, are solely your responsibility and the
responsibility of your Physicians and other
health care Providers. You and your Physicians
are responsible for deciding what medical care
should be rendered or received, and when and
how that care should be provided. Monroe
County BOCC is ultimately responsible for
determining whether expenses,which have
been or will be incurred for medical care are, or
will be, covered under this Booklet. In fulfilling
this responsibility, neither BCBSF nor Monroe
County BOCC will be deemed to participate in or
override the medical decisions of your health
care Provider.
Please note that the Hospital admission
notification requirement and any Blueprint For
Health Program may be discontinued or
modified at any time without notice to you or
your consent.
Blueprint for Health Programs 8-5
Section 9: Pre-existing Conditions Exclusion Period
Introduction 6. Genetic Information in the absence of a
diagnosis of the Condition;
Generally,there is no coverage under this
7• routine follow-up care of breast cancer after the
Booklet for Health Care Services to treat a
Pre-existing Condition, or Conditions arising person was determined to be free of breast
from a Pre-existing Condition, until you have cancer;
been continuously covered under this 8. Conditions arising from domestic violence; or
Booklet for a 12-month period. This 12-
month Pre-existing Condition exclusionary 9• inherited diseases of amino acid, organic acid,
period begins on the first day of the Waiting carbohydrate or fat metabolism as well as
Period if you are an initial enrollee; or your malabsorption originating from congenital
Effective Date of coverage under the Booklet defects present at birth or acquired during the
if you are a special or annual enrollee. This neonatal period.
exclusionary period also applies to any Genetic Information, as used above, means
prescription drug that is prescribed in information about genes,gene products, and
connection with a Pre-existing Condition. inherited characteristics that may derive from the
This Pre-existing Condition exclusionary individual or a family member. This includes
period does not apply to: information regarding carrier status and information
1. the Covered Plan Participant and each derived from laboratory tests that identify mutations
Covered Dependent who was covered in specific genes or chromosomes, physical medical
under the Group's prior medical plan on examinations,family histories, and direct analysis of
the date immediately preceding the genes or chromosomes.
Effective Date of coverage under this Pre-existing Condition Definition
Booklet;
2. you if you were enrolled during the Initial A Pre-existing Condition means any Condition
related to a physical or mental Condition, regardless
Enrollment Period prior to the Effective of the cause of the Condition,for which medical
Date of the Group; advice, diagnosis, care, or treatment was
3. you when the Group has elected to recommended or received during the six-month
waive, in writing, at the time of Group period immediately preceding:
Application the Pre-existing Conditions 1. the first day of your Waiting Period for initial
exclusionary period for all subsequent enrollees;or
Eligible Employees and/or Eligible 2. your Effective Date of coverage under the
Dependents; Group Health Plan for special and annual
4. any Condition for a Covered Person who enrollees.
is under the age of 19 as of the effective
date of this Benefit Booklet, or if enrolled Reducing the Pre-existing Conditions
thereafter, is under the age of 19 at the Exclusionary Period
time of enrollment; No matter whether you enroll when first eligible or at
5. pregnancy; a later date(such as an Annual Open Enrollment
Period or as a result of Special Enrollment), you
Pre-existing Condibons Exclusion Penod 9-1
may be able to reduce or even eliminate the 8. a health plan offered under chapter 89 of Title 5,
Pre-existing Conditions exclusionary period if United States Code;
you have prior Creditable Coverage.
9. a public health plan;
If you are enrolling when you are first eligible
10. a health benefit plan of the Peace Corps;
for coverage and you have no more than a
63 day break in Creditable Coverage as of 11. State Children's Health Insurance Program
your Enrollment Date under this Booklet, (CHIP);
your Pre-existing Conditions exclusionary 12. public health plans established by the federal
period will be reduced by the amount of prior government;or
Creditable Coverage you have.
1
If, on the other hand, you are enrolling under 3. public health plans established by foreign
this Booklet at any other time as allowed governments.
under its terms,such as during an Annual Proving Creditable Coverage
Open Enrollment Period or a Special
Enrollment Period, your Pre-existing You may provide a Prior/Concurrent Coverage
Conditions exclusionary period will be Affidavit or Certification of Creditable Coverage to
reduced by the amount of any Creditable prove the amount of time you were covered under
Coverage you have; provided there is no Creditable Coverage. Prior health insurers and/or
more than a 63 day break in coverage prior group health plans are required to provide a
to your Enrollment Date in this Booklet. certification of Creditable Coverage to you upon
If you have no Creditable Coverage or none termination of your coverage and at any time upon
that can reduce the Pre-existing Conditions request up to 24 months after termination of your
exclusionary period,the full 12-month Pre- prior health coverage. If you do not provide a
existing Conditions exclusionary period will certification,then you must provide some other
apply. evidence of Creditable Coverage such as a copy of
an ID card or health insurance bill from a prior
Creditable Coverage carrier and attest to the amount of time you were
covered under the Creditable Coverage.
Creditable Coverage is health care coverage
that may include any of the following:
1. a group health insurance plan;
2. individual health insurance;
3. Medicare Part A and Part B;
4. Medicaid;
5. benefits to members and certain former
members of the uniformed services and
their dependents;
6. a medical care program of the Indian
Health Service or of a tribal organization;
7. a State health benefits risk pool;
Pre-existing conditions Exclusion Penod 9-2
Section 10: Eligibility for Coverage
Each employee or other individual who is eligible the 60th day of continuous service or
to participate in the Monroe County Group Waiting Period.
Health Plan, and who meets and continues to Monroe County BOCC's coverage eligibility
meet the eligibility requirements described in this classifications may be expanded to include:
Booklet, shall be entitled to apply for coverage
under this Booklet. These eligibility 1. retired employees;
requirements are binding upon you and/or your 2. Constitutional Officers or their Employees;
eligible family members. No changes in the
eligibility requirements will be permitted except 3. additional job classifications;
as permitted by Monroe County BOCC. 4. employees of affiliated or subsidiary
Acceptable documentation may be required as companies of Monroe County BOCC; and
proof that an individual meets and continues to
meet the eligibility requirements such as a court 5. other individuals as determined by Monroe
order naming the Eligible Employee as the legal County BOCC.
guardian or appropriate adoption documentation Monroe County BOCC shall have sole discretion
described in the"Enrollment and Effective Date concerning the expansion of eligibility
of Coverage"section. classifications.
Eligibility Requirements for Covered Eligibility Requirements for
Plan Participants Dependent(s)
In order to be eligible to enroll as a Covered An individual who meets the eligibility criteria
Plan Participant, an individual must be an specified below is an Eligible Dependent and is
Eligible Employee or Eligible Retiree. An eligible to apply for coverage under this Booklet:
Eligible Employee must meet each of the
following requirements: 1. The Covered Plan Participant's spouse
under a legally valid existing marriage under
1. The employee must be a bona fide Federal Law.
employee of a Monroe County Employer,
participating in the Monroe County Group 2. The Covered Plan Participant's natural,
Health Plan; newborn,adopted, Foster, or step child(ren)
(or a child for whom the Covered Plan
2. The employee must be actively working 25 Participant has been court-appointed as
hours or more per week on a regular basis; legal guardian or legal custodian)who has
3. The employee must have completed the not reached the end of the Calendar Year in
applicable Waiting Period of 60 days of which he or she reaches age 26(or in the
continuous service; and case of a Foster Child, is no longer eligible
4. The employee must meet any additional under the Foster Child Program), regardless
eligibility requirement(s)required by Monroe of the dependent child's student or marital
County BOCC. status,financial dependency on the Covered
Plan Participant,whether the dependent
Note: Employees and qualified Dependents are child resides with the Covered Plan
eligible for coverage on the day following Participant, or whether the dependent child
Eligibility For Coverage 10-1
is eligible for or enrolled in any other group Handicapped Children
health plan. In the case of a handicapped dependent child,
3. The newborn child of a Covered Dependent such child is eligible to continue coverage as a
child who has not reached the end of the Covered Dependent, beyond the age of 26, if
Calendar Year in which he or she becomes the child is:
26. Coverage for such newborn child will 1. otherwise eligible for coverage under the
automatically terminate 18 months after the Group Health Plan;
birth of the newborn child.
2. incapable of self-sustaining employment by
Note: If a Covered Dependent child who has reason of mental retardation or physical
reached the end of the Calendar Year in which handicap; and
he or she becomes 26 obtains a dependent of
their own(e.g.,through birth or adoption)such 3. chiefly dependent upon the Covered Plan
newborn child will not be eligible for this Participant for support and maintenance
coverage and the Covered Dependent child will provided that the symptoms or causes of the
also lose his or her eligibility for this coverage. It child's handicap existed prior to the child's
is the Covered Plan Participant's sole 26th birthday.
responsibility to establish that a child meets the This eligibility shall terminate on the last day of
applicable requirements for eligibility. the month in which the dependent child no
This eligibility shall terminate on the last day of
longer meets the requirements for extended
the Calendar Year in which the dependent child eligibility as a handicapped child.
reaches age 26. Exception for Students on Medical Leave of
Extension of Eligibility for Dependent Absence from School
Children A Covered Dependent child who is a full-time or
A Covered Dependent child may continue part-time student at an accredited post-
coverage beyond the end of the Calendar Year secondary institution,who takes a physician
in which he or she reaches age 26, provided he certified medically necessary leave of absence
or she is: from school,will still be considered a student for
eligibility purposes under this Booklet for the
1. unmarried and does not have a dependent; earlier of 12 months from the first day of the
2. a Florida resident or a full-time or part-time leave of absence or the date the Covered
student; Dependent would otherwise no longer be eligible
for coverage under this Booklet.
3. not enrolled in any other health coverage
policy or group health plan; and
4. not entitled to benefits under Title XVIII of
the Social Security Act unless the child is a
handicapped dependent child.
This eligibility shall terminate on the last day of
the Calendar Year in which the dependent child
reaches age 30.
Eligibility For Coverage 1 0-Z
1
and Effective Date of Coverage
Section 11 .• Enrollmente g
Eligible Employees, Eligible Retirees and Employee/Retiree and the employee's spouse
Eligible Dependents may enroll for coverage under a legally valid existing marriage under
according to the provisions below. Federal Law or Domestic Partner.
Any Eligible Employee, Eligible Retiree or Employee/Child(ren)Coverage-This type of
Eligible Dependent who is not properly enrolled coverage provides coverage for the
will not be covered under this Benefit Booklet. Employee/Retiree and the covered child(ren)
Neither BCBSF nor Monroe County BOCC will only.
have any obligation whatsoever to any individual Employee/Family Coverage-This type of
who is not properly enrolled. coverage provides coverage for the
Any Employee, Eligible Retiree, or Eligible Employee/Retiree and the Covered Dependents.
Dependent who is eligible for coverage under There may be additional contribution amounts
this Booklet may apply for coverage according to for each Covered Dependent based on the
the provisions set forth below. coverage selected by Monroe County BOCC.
Enrollment Forms/Electing Coverage Enrollment Periods
To apply for coverage, you as the Eligible The enrollment periods for applying for coverage
Employee or Eligible Retiree must: are as follows:
1. complete and submit,through Monroe Initial Enrollment Period is the period of time
County BOCC Benefits Office,the during which an Eligible Employee or Eligible
Enrollment Form; Dependent is first eligible to enroll. It starts on
2. provide any additional information needed to the Eligible Employee's or Eligible Dependent's
determine eligibility, at the request of initial date of eligibility and ends no less than 30
BCBSF or Monroe County BOCC Benefits days later.
Office; Annual Open Enrollment Period is the period
3. pay any required contribution; and of time during which each Eligible Employee or
4. complete and submit,through Monroe Eligible Retiree is given an opportunity to select
County BOCC Benefits Office, an coverage from among the alternatives included
Enrollment Form to add Eligible in Monroe County BOCC's health benefit
Dependents. program. The period is established by Monroe
County BOCC, occurs annually, and will take
When making application for coverage,you place when specified by Monroe County BOCC.
must elect one of the types of coverage
available under Monroe County BOCC's Special Enrollment Period is the 30-day period
program. Such types may include: of time(unless otherwise noted)immediately
following a special circumstance during which an
Employee Only Coverage-This type of Eligible Employee or Eligible Dependent may
coverage provides coverage for the apply for coverage. Special circumstances are
Employee/Retiree only. described in the Special Enrollment Period
Employee/Spouse Coverage-This type of subsection.
coverage provides coverage for the
Enrollment and Effective Date of Coverage 1-1
Employee Enrollment Enrollment event,during the Special Enrollment
Period.
An Eligible Employee who fails to enroll during
the Initial Enrollment Period will not be covered Note: For a Covered Dependent child who has
and may only enroll under this Benefit Booklet reached the end of the Calendar Year in which
during the next Annual Open Enrollment Period he or she becomes 26 and the Covered
established by Monroe County BOCC, or in the Dependent child obtains a dependent of their
case of a Special Enrollment event, during the own(e.g.,through birth or adoption), such
Special Enrollment Period. The Effective Date newborn child will not be eligible for this
will be the date specified by Monroe County coverage and cannot enroll. Further, such
BOCC. Covered Dependent child will also lose his or
her eligibility for this coverage.
Dependent Enrollment Adopted Newborn Child—To enroll an
An individual may be added upon becoming an adopted newborn child,the Covered Plan
Participant must submit an Enrollment Form
Eligible Dependent of a Covered Plan through Monroe County BOCC Benefits Office to
Participant. Below are special rules for certain
BCBSF during the 30-day period immediately
Eligible Dependents. following the date of birth. The Effective Date of
Newborn Child—To enroll a newborn child who coverage for an adopted newborn child, eligible
is an Eligible Dependent,the Covered Plan for coverage,will be the moment of birth,
Participant must submit an Enrollment Form to provided that a written agreement to adopt such
BCBSF through Monroe County BOCC Benefits child has been entered into by the Covered Plan
Office during the 30-day period immediately Participant prior to the birth of such child,
following the date of birth. The Effective Date of whether or not such an agreement is
coverage for a newborn child will be the date of enforceable. The Covered Plan Participant may
birth. be required to provide any information and/or
If timely notice is given, no additional documents that are deemed necessary in order
contribution will be charged for coverage of the to administer this provision.
newborn child for not less than 30 days after the If timely notice is given, no additional
birth of the child. If timely notice is not received, contribution will be charged for coverage of the
the applicable contribution will be charged from adopted newborn child for not less than 30 days
the date of birth. The applicable contribution for after the birth of the child. If timely notice is not
the child will be charged after the initial 30-day received,the applicable contribution will be
period in either case. Coverage will not be charged from the date of birth. The applicable
denied for a newborn child if the Covered Plan contribution for the child will be charged after the
Participant provides notice to Monroe County initial 30-day period in either case. Coverage
BOCC Benefits Office and an Enrollment Form will not be denied for an adopted newborn child
is received within the 60-day period of the birth if the Covered Plan Participant provides notice
of the child and any applicable contribution is to Monroe County BOCC Benefits Office and an
paid back to the date of birth. Enrollment Form is received within the 60-day
If the newborn is not enrolled within sixty days of period of the birth of the adopted newborn child
the date of birth,the newborn child will not be and any applicable contribution is paid back to
covered, and may only be enrolled under this the date of birth.
Benefit Booklet during an Annual Open If the adopted newborn child is not enrolled
Enrollment Period,or in the case of a Special within sixty days of the date of birth,the adopted
Enrollment and Effective Date of Coverage 11-2
newborn child will not be covered, and may only must be submitted to BCBSF through Monroe
be enrolled under this Benefit Booklet during an County BOCC Benefits Office. It is the
Annual Open Enrollment Period, or in the case responsibility of the Covered Plan Participant to
of a Special Enrollment event,during the Special notify BCBSF through Monroe County BOCC
Enrollment Period. Benefits Office if the adoption does not take
If the adopted newborn child is not ultimately place. Upon receipt of this notification,we will
placed in the residence of the Covered Plan terminate the coverage of the child as of the
Participant,there shall be no coverage for the Effective Date of the adopted child upon receipt
adopted newborn child. It is your responsibility of the written notice.
as the Covered Plan Participant to notify Monroe If the Covered Plan Participant's status as a
County BOCC Benefits Office within ten foster parent is terminated, coverage will end for
calendar days of the date that placement was to any Foster Child. It is the responsibility of the
occur if the adopted newborn child is not placed Covered Plan Participant to notify BCBSF
in your residence. through Monroe County BOCC Benefits Office
Adopted/Foster Children—To enroll an that the Foster Child is no longer in the Covered
adopted or Foster Child,the Covered Plan Plan Participant's care. Upon receipt of this
Participant must submit an Enrollment Form notification, coverage for the child will be
during the 30-day period immediately following terminated on the date the Covered Plan
the date of placement. The Effective Date for an Participant's status as a foster parent
adopted or Foster child(other than an adopted terminated.
newborn child)will be the date such adopted or Marital Status—The Covered Plan Participant
Foster child is placed in the residence of the may apply for coverage of an Eligible Dependent
Covered Plan Participant in compliance with due to a legally valid existing marriage under
applicable law. The Covered Plan Participant Federal Law. To apply for coverage,the
may be required to provide any information Covered Plan Participant must complete the
and/or documents deemed necessary in order to Enrollment Form through Monroe County BOCC
properly administer this section. Benefits Office and forward it to BCBSF. The
In the event Monroe County BOCC Benefits Covered Plan Participant must make application
Office is not notified within 30 days of the date of for enrollment within 30 days of the marriage.
placement,the child will be added as of the date The Effective Date of coverage for an Eligible
of placement so long as Covered Plan Dependent who is enrolled as a result of
Participant provides notice to Monroe County marriage is the date of the marriage.
BOCC Benefits Office,and we receive the Court Order—The Covered Plan Participant
Enrollment Form within 60 days of the may apply for coverage for an Eligible
placement. If the adopted or Foster Child is not Dependent outside of the Initial Enrollment
enrolled within sixty days of the date of Period and Annual Open Enrollment Period if a
placement, the adopted or Foster Child will not court has ordered coverage to be provided for a
be covered, and may only be enrolled under this minor child under their group coverage. To
Benefit Booklet during an Annual Open apply for coverage,the Covered Plan Participant
Enrollment Period,or in the case of a Special must complete an Enrollment Form through
Enrollment event, during the Special Enrollment Monroe County BOCC Benefits Office and
Period. For all children covered as adopted forward it to BCBSF. The Covered Plan
children, if the final decree of adoption is not Participant must make application for enrollment
issued,coverage shall not be continued for the within 30 days of the court order. The Effective
proposed adopted Child. Proof of final adoption Date of coverage for an Eligible Dependent who
Enrollment and Effective Date of Coverage 11-3
is enrolled as a result of a court order is the date 1. If you lose your coverage under another
required by the court. group health benefit plan(as an employee
or dependent), or coverage under other
Annual Open Enrollment Period health insurance(except in the case of loss
of coverage under a Children's Health
Eligible Employees and/or Eligible Dependents Insurance Program (CHIP)or Medicaid, see
who did not apply for coverage during the Initial #3 below),or COBRA continuation
Enrollment Period or a Special Enrollment coverage that you were covered under at
Period may apply for coverage during an Annual the time of initial enrollment provided that:
Open Enrollment Period. The Eligible Employee
may enroll by completing the Enrollment Form a) when offered coverage under this plan
during the Annual Open Enrollment Period. at the time of initial eligibility, you stated,
in writing,that coverage under a group
The effective date of coverage for an Eligible health plan or health insurance
Employee and any Eligible Dependent(s)will be coverage was the reason for declining
the date established by Monroe County BOCC enrollment; and
Benefits Office.
b) you lost your other coverage under a
Eligible Employees who do not enroll or change group health benefit plan or health
their coverage selection during the Annual Open insurance coverage(except in the case
Enrollment Period, must wait until the next of loss of coverage under a CHIP or
Annual Open Enrollment Period, unless the Medicaid, see#3 below)as a result of
Eligible Employee or the Eligible Dependent is termination of employment, reduction in
enrolled due to a special circumstance as the number of hours you work, reaching
outlined in the Special Enrollment Period or exceeding the maximum lifetime of all
subsection of this section. benefits under other health coverage,
the employer ceased offering group
Special Enrollment Period health coverage, death of your spouse,
divorce, legal separation or employer
An Eligible Employee and/or the Employee's contributions toward such coverage was
Eligible Dependent(s)may apply for coverage terminated; and
outside of the Initial Enrollment Period and
Annual Enrollment Period as a result of a special c) you submit the applicable Enrollment
enrollment event. To apply for coverage,the Form to the Group within 30 days of the
Eligible Employee and/or the Employee's date your coverage was terminated
Eligible Dependent(s)must complete the Note: Loss of coverage for failure to pay
applicable Enrollment Form and forward it to your required contribution/premium on a
Monroe County BOCC Benefits Office within the timely basis or for cause(such as making a
time periods noted below for each special fraudulent claim or an intentional
enrollment event. misrepresentation of a material fact in
An Eligible Employee and/or the Employee's connection with the prior health coverage)is
Eligible Dependent(s)may apply for coverage if not a qualifying event for special enrollment.
one of the following special enrollment events or
occurs and the applicable Enrollment Form is 2. If when offered coverage under this plan at
submitted to Monroe County BOCC Benefits the time of initial eligibility, you stated, in
Office within the indicated time periods: writing,that coverage under a group health
plan or health insurance coverage was the
Enrollment and Effective Date of Coverage 11-4
i
I
!
reason for declining enrollment; and you get Condition exclusionary period, and Waiting
mauled or obtain a dependent through birth, Period)are applicable to rehired employees and
adoption or placement in anticipation of their Eligible Dependents.
adoption and you submit the applicable
Enrollment Form to Monroe County BOCC
Benefits Office within 30 days of the date of
the event.
or
3. If you or your Eligible Dependent(s)lose
coverage under a CHIP or Medicaid due to
loss of eligibility for such coverage or
become eligible for the optional state
premium assistance program and you
submit the applicable Enrollment Form to
Monroe County BOCC Benefits Office within
60 days of the date such coverage was
terminated or the date you become eligible
for the optional state premium assistance
program.
The Effective Date of coverage for you and your
Eligible Dependents added as a result of a
special enrollment event is the date of the
special enrollment event. Eligible Employees or
Eligible Dependents who do not enroll or change
their coverage selection during the Special
Enrollment Period must wait until the next
Annual Open Enrollment Period(See the
Dependent Enrollment subsection of this section
for the rules relating to the enrollment of Eligible
Dependents of a Covered Plan Participant).
Other Provisions Regarding
Enrollment and Effective Date of !
Coverage
i
Individuals who are rehired as employees of
Monroe County BOCC or any of the
Constitutional Officers or their Employees are
considered newly hired employees for purposes
of this section. The provisions of the Group
Health Plan(which includes this Booklet)which
are applicable to newly hired employees and
their Eligible Dependents(e.g., enrollment,
Effective Dates of coverage, Pre-existing
Enrollment and Effective Date of Coverage 11-5
Section 12: Termination of Coverage
Termination of a Covered Plan 4. last day of the Calendar Year that the
Participant's Coverage Covered Dependent child no longer meets
any of the applicable eligibility requirements;
A Covered Plan Participant's coverage under
this Benefit Booklet will automatically terminate 5. date specified by Monroe County BOCC that
the Dependent's coverage is terminated for
at 12:01 a.m.:
cause(see the Termination of Individual
1. on the date the Group Health Plan Coverage for Cause subsection).
terminates;
In the event you as the Covered Plan Participant
2. on the date the ASO Agreement between wish to delete a Covered Dependent from
BCBSF and Monroe County BOCC coverage, an Enrollment Form must be
terminates; forwarded to BCBSF through Monroe County
3. on the last day of the first month that the BOCC Benefits Office.
Covered Plan Participant fails to continue to In the event you as the Covered Plan Participant
meet any of the applicable eligibility wish to terminate a spouse's coverage,(e.g., in
requirements; the case of divorce),you must submit an
4. on the date specified by Monroe County Enrollment Form to Monroe County BOCC, prior
BOCC that the Covered Plan Participant's to the requested termination date or within 10
coverage is terminated for cause(see the days of the date the divorce is final,whichever is
Termination of an Individual Coverage for applicable.
Cause subsection); or
Termination of an Individual's
5. on the date specified by Monroe County Coverage for Cause
BOCC that the Covered Plan Participant's
coverage terminates. In the event any of the following occurs, Monroe
County BOCC may terminate an individual's
Termination of a Covered coverage for cause:
Dependent's Coverage
1. fraud, material misrepresentation or
A Covered Dependent's coverage will omission in applying for coverage or
automatically terminate at 12:01 a.m. on the benefits; or
date: 2. the knowing misrepresentation, omission or
1. the Group Health Plan terminates; the giving of false information on Enrollment
Forms or other forms completed, by or on
2. the Covered Plan Participant's coverage your behalf.
terminates for any reason;
3. the Dependent becomes covered under an Notice of Termination
alternative health benefits plan which is
It is Monroe County BOCC's responsibility to
offered through or in connection with the immediately notify you of your termination or that
Group Health Plan;
of your Covered Dependents for any reason.
Terrronabon of Coverage 12-1
Certification of Creditable Coverage
In the event coverage terminates for any reason,
a written certification of Creditable Coverage will
be issued to you.
The certification of Creditable Coverage will
indicate the period of time you were enrolled
i
under Monroe County BOCC's Group Health
Plan. Creditable Coverage may reduce the
length of any Pre-existing Condition
exclusionary period by the length of time you
had prior Creditable Coverage.
Upon request, another certification of Creditable
Coverage will be sent to you within a 24-month
period after termination of coverage. You may
call the customer service phone number
indicated in this Booklet or on your ID Card to
request the certification.
The succeeding carrier will be responsible for
determining if coverage meets the qualifying
Creditable Coverage guidelines(e.g., no more
than a 63-day break in coverage).
Termination of Coverage 12-2
Section 13: Continuing Coverage Under COBRA
A federal continuation of coverage law, known months)if you or your Covered
as the Consolidated Omnibus Budget Dependent(s)is/are totally disabled(as
Reconciliation Act of 1985(COBRA), as defined by the Social Security Administration
amended, may apply to your Group Health Plan. (SSA))at the time of your termination,
If COBRA applies, you or your Covered reduction in hours or within the first 60 days
Dependents may be entitled to continue of COBRA continuation coverage. The
coverage for a limited period of time, if you meet Covered Person must supply notice of the
the applicable requirements, make a timely disability determination to Monroe County
election, and pay the proper amount required to BOCC Benefits Office within 18 months of
maintain coverage. becoming eligible for continuation coverage
You must contact Monroe County BOCC and no later than 60 days after the SSA's
Benefits Office to determine if you or your determination date.
Covered Dependent(s)are entitled to COBRA 2. Your Covered Dependent(s)may elect to
continuation of coverage. Monroe County continue their coverage for a period not to
BOCC is solely responsible for meeting all of the exceed 36 months in the case of:
obligations under COBRA, including the a) the Covered Plan Participant's
obligation to notify all Covered Persons of their entitlement to Medicare;
rights under COBRA. If you fail to meet your
obligations under COBRA and this Benefit b) divorce or legal separation of the
Booklet, Monroe County BOCC will not be liable Covered Plan Participant;
for any claims incurred by you or your Covered c) death of the Covered Plan Participant;
Dependent(s)after termination of coverage.
d) the employer files bankruptcy(subject to
A summary of your COBRA rights and the bankruptcy court approval); or
general conditions for qualification for COBRA
continuation coverage is provided below. e) a dependent child may elect the 36
month extension if the dependent child
The following is a summary of what you may ceases to be an Eligible Dependent
elect, if COBRA applies to Monroe County under the terms of Monroe County
BOCC and you are eligible for such coverage: BOCC's coverage.
1. You may elect to continue this coverage for Children born to or placed for adoption with the
a period not to exceed 18 months"in the Covered Plan Participant during the continuation
case of: coverage periods noted above are also eligible
a) termination of employment of the for the remainder of the continuation period.
Covered Plan Participant other than for Additional requirements applicable to
gross misconduct;or continuation of coverage under COBRA are set
b) reduced hours of employment of the forth below:
Covered Plan Participant. 1. Monroe County BOCC must notify you of
*Note: You and/or your Covered your continuation of coverage rights under
Dependent(s)are eligible for an 11 month COBRA within 14 days of the event which
extension of the 18 month COBRA creates the continuation option. If coverage
continuation option above(to a total of 29 would be lost due to Medicare entitlement,
Continuing Coverage Under COBRA 13-1
divorce,legal separation or the failure of a An election by a Covered Plan Participant or
Covered Dependent child to meet eligibility Covered Dependent spouse shall be deemed to
requirements,you or your Covered be an election for any other qualified beneficiary
Dependent must notify Monroe County related to that Covered Plan Participant or
BOCC Benefits Office,in writing,within 60 Covered Dependent spouse, unless otherwise
days of any of these events. Monroe specified in the election form.
County BOCC's 14-day notice requirement Note: This section shall not be interpreted to
runs from the date of receipt of such notice. grant any continuation rights in excess of
2. You must elect to continue the coverage those required by COBRA and/or Section
within 60 days of the later of: 4980B of the Internal Revenue Code.
a) the date that the coverage terminates; or Additionally,this Benefit Booklet shall be
deemed to have been modified,and shall be
b) the date the notification of continuation of interpreted, so as to comply with COBRA
coverage rights is sent by Monroe and changes to COBRA that are mandatory
County BOCC. with respect to Monroe County BOCC.
3. COBRA coverage will terminate if you
become covered under any other group
health insurance plan. However, COBRA
coverage may continue if the new group
health insurance plan contains exclusions or
limitations due to a Pre-existing Condition
that would affect your coverage.
4. COBRA coverage will terminate if you
become entitled to Medicare.
5. If you are totally disabled and eligible and
elect to extend your continuation of
coverage, you may not continue such
extension of coverage more than 30 days
after a determination by the Social Security
Administration that you are no longer
disabled. You must inform Monroe County
BOCC Benefits Office of the Social Security
Administration's determination within 30
days of such determination.
6. You must meet all contribution
requirements,and all other eligibility
requirements described in COBRA, and,to
the extent not inconsistent with COBRA, in
the Group Health Plan.
7. COBRA coverage will terminate on the date
Monroe County BOCC ceases to provide
group health coverage to its employees.
Continuing Coverage Under COBRA 13-2
Section 14: Conversion Privilege
Eligibility Criteria for Conversion Additionally, you are not entitled to a converted
You are entitled to apply for a BCBSF individual policy if:
insurance conversion policy(hereinafter referred 1. you are eligible for or covered under the
to as a"converted policy"or"conversion policy") Medicare program;
if:
2. you failed to pay, on a timely basis,the
1. you were continuously covered for at least contribution required for coverage under the
three months under the Group Health Plan, Group Health Plan;
and/or under another group policy that
provided similar benefits immediately prior to 3. the Group Health Plan was replaced within
the Group Health Plan; and 31 days after termination by any group
policy, contract, plan, or program, including
2. your coverage was terminated for any aself-insured plan or program,that provides
reason, including discontinuance of the benefits similar to the benefits provided
Group Health Plan in its entirety and
termination of continued coverage under under this Booklet; or
COBRA. 4. a) you fall under one of the following
Notify BCBSF in writing or by telephone if you categories and meet the requirements of
are interested in a conversion policy. Within 14 4.b. below:
days of such notice, BCBSF will send you a I. you are covered under any Hospital,
conversion policy application, premium notice surgical, medical or major medical
and outline of coverage. The outline of policy or contract or under a
coverage will contain a brief description of the prepayment plan or under any other
benefits and coverage, exclusions and plan or program that provides
limitations,and the applicable Deductible(s)and benefits which are similar to the
Coinsurance provisions. benefits provided under this Booklet;
BCBSF must receive a completed application or
for a converted policy, and the applicable ii. you are eligible,whether or not
premium payment,within the 63-day period covered, under any arrangement of
beginning on the date the coverage under
the Group Health Plan terminated. If coverage for individuals in a group,
whether on an insured, uninsured,
coverage has been terminated, due to the
non-payment of employee contribution by or partially insured basis,for
Monroe County BOCC, BCBSF must receive benefits similar those provided
the completed converted policy application under this Booklet; or
and the applicable premium payment within iii. benefits similar to the benefits
the 63-day period beginning on the date provided under this Booklet are
notice was given that the Group Health Plan provided for or are available to you
terminated. pursuant to or in accordance with
In the event BCBSF does not receive the the requirements of any state or
converted policy application and the initial federal law(e.g., COBRA,
premium payment within such 63-day period, Medicaid);and
your converted policy application will be denied
and you will not be entitled to a converted policy.
Conversion Privilege 14-1
b) the benefits provided under the sources
referred to in paragraph 4.a.i or the
benefits provided or available under the
source referred to in paragraph 4.a.ii.
and 4.a.iii. above,together with the
benefits provided by our converted
policy would result in over-insurance in
accordance with our over-insurance
standards, as determined by us.
Neither Monroe County BOCC nor BCBSF
has any obligation to notify you of this
conversion privilege when your coverage
terminates or at any other time. It is your
sole responsibility to exercise this
conversion privilege by submitting a BCBSF
converted policy application and the initial
premium payment to us within 63 days of the
termination of your coverage under this
Benefit Booklet. The converted policy may
be issued without evidence of insurability
and shall be effective the day following the
day your coverage under this Benefit Booklet
terminated.
Note: Our converted policies are not a
continuation of coverage under COBRA or any
other states'similar laws. Coverage and
benefits provided under a converted policy will
not be identical to the coverage and benefits
provided under this Booklet. When applying for
our converted policy,you have two options: 1)a
converted policy providing major medical
coverage meeting the requirements of
627.6675(10)Florida Statutes or 2)a converted
policy providing coverage and benefits identical
to the coverage and benefits required to be
provided under a small employer standard
health benefit plan pursuant to Section
627.6699(12)Florida Statutes. In any event,we
will not be required to issue a converted policy
unless required to do so by Florida law. We
may have other options available to you. Call
the telephone number on your Identification card
for more information.
Conversion Privilege 14-2
Section 15: Extension of Benefits
Extension of Benefits perform those normal day-to-day activities
which you would otherwise perform and you
In the event the Group Health Plan is require regular care and attendance by a
terminated, coverage will not be provided under Physician.
this Benefit Booklet for any Service rendered on
or after the termination date. The extension of 2. In the event you are receiving covered
benefits provisions described below only apply dental treatment as of the termination date
of the Group Health Plan a limited extension
when the entire Group Health Plan is
of such covered dental treatment will be
terminated. The extension of benefits described
in this section do not apply when your coverage provided under this Benefit Booklet if:
terminates if the Group Health Plan remains in a) a course of dental treatment or dental
effect. The extension of benefits provisions are procedures were recommended in
subject to all of the other provisions, including writing and commenced in accordance
the limitations and exclusions. with the terms specified herein while you
Note: It is your sole responsibility to provide were covered under the Group Health
acceptable documentation showing that you are Plan;
entitled to an extension of benefits. b) the dental procedures were procedures
1. In the event you are totally disabled on the for other than routine examinations,
termination date of the Group Health Plan as prophylaxis, x-rays, sealants, or
a result of a specific Accident or illness orthodontic services; and
incurred while you were covered under this c) the dental procedures were performed
Booklet, as determined by us,a limited within 90 days after the Group Health
extension of benefits will be provided under Plan terminated.
this Benefit Booklet for the disabled This extension of benefits is for Covered
individual only. This extension of benefits is Services necessary to complete the
for Covered Services necessary to treat the dental treatment only. This extension of
disabling Condition only. This extension of benefits will automatically terminate at
benefits will only continue as long as the the end of the 90-day period beginning
disability is continuous and uninterrupted. In
on the termination date of the Group
any event,this extension of benefits will Health Plan or on the date you become
automatically terminate at the end of the 12- covered under a succeeding insurance,
month period beginning on the termination health maintenance organization or self- j
date of the Group Health Plan. insured plan providing coverage or
For purposes of this section, you will be Services for similar dental procedures.
considered "totally disabled"only if, in our You are not required to be totally
or Monroe County BOCC's opinion, you are disabled in order to be eligible for this
unable to work at any gainful job for which extension of benefits.
you are suited by education,training, or Please refer to the Dental Care category of
experience,and you require regular care the"What Is Covered?"section for a
and attendance by a Physician. You are description of the dental care Services
totally disabled only if, in our or Monroe covered under this Booklet.
County BOCC's opinion, you are unable to
Extension of Benefits 15-1
i
3. In the event you are pregnant as of the
termination date of the Group Health Plan,a
limited extension of the maternity expense
benefits included in this Booklet will be
available, provided the pregnancy
commenced while the pregnant individual
was covered under the Group Health Plan,
as determined by us or Monroe County
BOCC. This extension of benefits is for
Covered Services necessary to treat the
pregnancy only. This extension of benefits
will automatically terminate on the date of
the birth of the child. You are not required to
be Totally Disabled in order to be eligible for
this extension of benefits.
I
I
i
I �
I
I
I
� I
I
I
I
Extension of Benefits 15-2
Section 16: The Effect of Medicare Coverage/Medicare
Secondary Payer Provisions
When you become covered under Medicare and disability whose employer has less than 100
continue to be eligible and covered under this employees, retirees and/or their spouses over
Benefit Booklet,coverage under this Benefit the age of 65). Also, if coverage under this
Booklet will be primary and the Medicare Benefit Booklet was primary prior to ESRD
benefits will be secondary, but only to the extent entitlement,then coverage hereunder will
required by law. In all other instances, coverage remain primary for the ESRD coordination
under this Benefit Booklet will be secondary to period. If you become eligible for Medicare due
any Medicare benefits. To the extent the to ESRD, coverage will be provided,as
benefits under this Benefit Booklet are primary, described in this section, on a primary basis for
claims for Covered Services should be filed with 30 months.
BCBSF first.
Disabled Active Individuals
Under Medicare, Monroe County BOCC MAY
NOT offer, subsidize, procure or provide a If you are entitled to Medicare coverage
Medicare supplement policy to you. Also, because of a disability other than ESRD,
Monroe County BOCC MAY NOT induce you to Medicare benefits will be secondary to the
decline or terminate your group health insurance benefits provided under this Benefit Booklet
coverage and elect Medicare as primary payer. provided that:
If you become 65 or become eligible for Monroe County BOCC employed at least 100 or
Medicare due to End Stage Renal Disease more full-time or part-time employees on 50%or
("ESRD"), you must immediately notify Monroe more of its regular business days during the
County BOCC Benefits Office. previous Calendar Year. If the Group Health
Plan is a multi-employer plan, as defined by
Individuals With End Stage Renal Medicare, Medicare benefits will be secondary if
Disease at least one employer participating in the plan
If you are entitled to Medicare coverage covered 100 or more employees under the plan
because of ESRD, coverage under this Benefit on 50%or more of its regular business days
Booklet will be provided on a primary basis for during the previous Calendar Year.
30 months beginning with the earlier of: Miscellaneous
1. the month in which you became entitled to
Medicare Part"A" ESRD benefits;or 1. This section shall be subject to, modified (if
necessary)to conform to or comply with,
2. the first month in which you would have and interpreted with reference to the
been entitled to Medicare Part"A" ESRD requirements of federal statutory and
benefits if a timely application had been regulatory Medicare Secondary Payer
made. provisions as those provisions relate to
If Medicare was primary prior to the time you Medicare beneficiaries who are covered
became eligible due to ESRD,then Medicare under this Benefit Booklet.
will remain primary(i.e., persons entitled due to
The Effect of Medicare Coverage/Medicare Secondary Payer Provisions 16-1
2. BCBSF will not be liable to Monroe County
BOCC or to any individual covered under
this Benefit Booklet on account of any
nonpayment of primary benefits resulting
from any failure of performance of Monroe
County BOCC's obligations as described in
this section.
The Effect of Medicare Coverage/Medicare Secondary Payer Provisions 16-2
Section 17: Duplication of Coverage Under Other Health
Plans/Programs
Coordination of Benefits with which the law permits coordination of
benefits;
Coordination of Benefits("COB")is a limitation
of coverage and/or benefits to be provided under 4. Medicare, as described in "The Effect of
Medicare Coverage/Medicare Secondary
this Benefit Booklet.
Payer Provisions"section; and
COB determines the manner in which expenses
will be paid when you are covered under more 5. to the extent permitted by law, any other
than one health plan, program,or policy government sponsored health insurance
providing benefits for Health Care Services. program.
COB is designed to avoid the costly duplication The amount of payment, if any, when benefits
of payment for Covered Services. It is your are coordinated under this section, is based on
responsibility to provide BCBSF and Monroe whether or not the benefits under this Benefit
County BOCC Benefits Office information Booklet are primary. When primary, payment
concerning any duplication of coverage under will be made for Covered Services without
any other health plan, program,or policy you or regard to coverage under other plans. When the
your Covered Dependents may have. This benefits under this Benefit Booklet are not
means you must notify BCBSF and Monroe primary, payment for Covered Services may be
County BOCC Benefits Office in writing if you reduced so that total benefits under all your
have other applicable coverage or if there is no plans will not exceed 100 percent of the total
other coverage. You may be requested to reasonable expenses actually incurred for
provide this information at initial enrollment, by Covered Services. For purposes of this section,
written correspondence annually thereafter, or in in the event you receive Covered Services from
connection with a specific Health Care Service an In-Network Provider or an Out-of-Network
you receive. If the information is not received, Provider who participates in the Traditional
claims may be denied and you will be Program, "total reasonable expenses"shall
responsible for payment of any expenses related mean the total amount required to be paid to the
to denied claims. Provider pursuant to the applicable agreement
Health plans, programs or policies which may be BCBSF or another Blue Cross and/or Blue
subject to COB include, but are not limited to, Shield organization has with such Provider. In
the following which will be referred to as the event that the primary payer's payment
"plan(s)"for purposes of this section: exceeds the Allowed Amount, no payment
will be made for such Services.
1. any group or non-group health insurance,
group-type self-insurance, or HMO plan; The following rules shall be used to establish the
order in which benefits under the respective
2. any group plan issued by any Blue Cross plans will be determined:
and/or Blue Shield organization(s);
1. When you are covered as a Covered
3. any other plan, program or insurance policy, Dependent and the other plan covers you as
including an automobile PIP insurance
policy and/or medical payment coverage
Duplication of Coverage Under Other Health Plans/Programs 17-1
other than a dependent,the Group Health 5. When rules 1, 2, 3, and 4 above do not
Plan will be secondary. establish an order of benefits,the plan which
2. When the Group Health Plan covers a has covered you the longest shall be
dependent child whose parents are not primary.
separated or divorced: The Group Health Plan will not coordinate
benefits against an indemnity-type policy, an
a) the plan of the parent whose birthday, excess insurance policy, a policy with
excluding year of birth,falls earlier in the coverage limited to specified illnesses or
year will be primary; or accidents, or a Medicare supplement policy.
b) if both parents have the same birthday, 6. If you are covered under a COBRA
excluding year of birth, and the other continuation plan as a result of the purchase
plan has covered one of the parents of coverage as provided under the
longer than us, the Group Health Plan Consolidated Omnibus Budget
will be secondary. Reconciliation Act of 1985, as amended,
3. When the Group Health Plan covers a and also under another group plan,the
dependent child whose parents are following order of benefits applies:
separated or divorced: a) first,the plan covering the person as an
a) if the parent with custody is not employee,or as the employee's
remarried,the plan of the parent with Dependent; and
custody is primary; b) second,the coverage purchased under
b) if the parent with custody has remarried, the plan covering the person as a former
the plan of the parent with custody is employee, or as the former employee's
primary;the stepparent's plan is Dependent provided according to the
secondary; and the plan of the parent provisions of COBRA.
without custody pays last; 7. If the other plan does not have rules that
c) regardless of which parent has custody, establish the same order of benefits as
whenever a court decree specifies the under this Booklet,the benefits under the
parent who is financially responsible for other plan will be determined primary to the
the child's health care expenses,the benefits under this Booklet.
plan of that parent is primary.
Coordination of benefits shall not be permitted
4. When the Group Health Plan covers a against an indemnity-type policy, an excess
dependent child and the dependent child is insurance policy as defined in Florida Statutes
also covered under another plan: Section 627.635, a policy with coverage limited
a) the plan of the parent who is neither laid to specified illnesses or accidents,or a Medicare
off nor retired will be primary;or supplement policy.
b) if the other plan is not subject to this Non-Duplication of Government
rule, and if, as a result, such plan does Programs and Worker's
not agree on the order of benefits,this Compensation
paragraph shall not apply.
The benefits under this Booklet shall not
duplicate any benefits to which you or your
Duplication of Coverage Under Other Health Plans/Programs 17-2
Covered Dependents are entitled to or eligible
for under government programs(e.g., Medicare,
Medicaid,Veterans Administration)or Worker's
Compensation to the extent allowed by law, or
under any extension of benefits of coverage
under a prior plan or program which may be
provided or required by law.
Duplication of Coverage Under Other Health Plans/Programs 17-3
Section 18: Subrogation
In the event payment is made under this Benefit legal representative shall promptly notify BCBSF
Booklet to you or on your behalf for any claim in in writing of any settlement negotiations prior to
connection with or arising from a Condition entering into any settlement agreement, shall
resulting, directly or indirectly,from an disclose to BCBSF any amount recovered from
intentional act or from the negligence or fault of any person or entity that may be liable, and shall
any third person or entity, Monroe County BOCC not make any distributions of settlement or
and/or the Group Health Plan,to the extent of judgement proceeds without Monroe County
any such payment, shall be subrogated to all BOCC's prior written consent. No waiver,
causes of action and all rights of recovery you release of liability, or other documents executed
have against any person or entity. Such by you without such notice to BCBSF shall be
subrogation rights shall extend and apply to any binding upon Monroe County BOCC.
settlement of a claim, regardless of whether
litigation has been initiated. BCBSF may
recover, on behalf of Monroe County BOCC
and/or the Group Health Plan,the amount of any
payments made on your behalf minus BCBSF or
Monroe County BOCC's pro rata share for any
costs and attorney fees incurred by you in
pursuing and recovering damages. BCBSF may
subrogate, on behalf of Monroe County BOCC
and/or the Group Health Plan,against all money
recovered regardless of the source of the money
including, but not limited to, uninsured motorist
coverage. Although Monroe County BOCC
may, but is not required to,take into
consideration any special factors relating your
specific case in resolving the subrogation claim,
Monroe County BOCC will have the first right of
recovery out of any recovery or settlement
amount you are able to obtain even if you or
your attorney believes that you have not been
made whole for your losses or damages by the
amount of the recovery or settlement.
You must promptly execute and deliver such
instruments and papers pertaining to such
settlement of claims, settlement negotiations, or
litigation as may be requested by BCBSF or
Monroe County BOCC,and shall do whatever is
necessary to enable BCBSF or Monroe County
BOCC to exercise Monroe County BOCC's
subrogation rights and shall do nothing to
prejudice such rights. Additionally, you or your
I
Subrogation 18-1
Section 19: Right of Reimbursement
If any payment under this Benefit Booklet is
made to you or on your behalf with respect to
any injury or illness resulting from the intentional
act,negligence, or fault of a third person or
entity, Monroe County BOCC and/or the Group
Health Plan will have a right to be reimbursed by
you(out of any settlement or judgment proceeds
you recover)one dollar($1.00)for each dollar
paid under the terms of the Group Health Plan
minus a pro rata share for any costs and
attorney fees incurred in pursuing and
recovering such proceeds.
Monroe County BOCC's and/or the Group
Health Plan's right of reimbursement will be in
addition to any subrogation right or claim
available to Monroe County BOCC, and you
must execute and deliver such instruments or
papers pertaining to any settlement or claim,
settlement negotiations, or litigation as may be
requested by BCBSF on behalf of Monroe
County BOCC, and/or the Group Health Plan,to
exercise Monroe County BOCC's and/or the
Group Health Plan's right of reimbursement
hereunder. You or your lawyer must notify us,
by certified or registered mail, if you intend to
claim damages from someone for injuries or
illness. You must do nothing to prejudice
Monroe County BOCC's and/or the Group
Health Plan's right of reimbursement hereunder
and no waiver, release of liability, or other
documents executed by you,without notice to us
and our written consent, acting on behalf of
Monroe County SOCC, will be binding upon
Monroe County BOCC.
Right of Reimbursement 19-1
Section 20: Claims Processing
Introduction Post-Service Claims
This section is intended to: How to File a Post-Service Claim
• help you understand what you or your We have defined and described the three types
treating Providers must do, under the terms of claims that may be submitted to us. Our
of this Benefit Booklet, in order to obtain experience shows that the most common type of
payment for expenses for Covered Services claim we will receive from you or your treating
they have rendered or will render to you; Providers will likely be Post-Service Claims.
and In-Network Providers have agreed to file Post-
• provide you with a general description of the Service Claims for Services they render to you.
applicable procedures we will use for In the event a Provider who renders Services to
making Adverse Benefit Determinations, you does not file a Post-Service Claim for such
Concurrent Care Decisions and for notifying Services, it is your responsibility to file it with us.
you when we deny benefits. We must receive a Post-Service Claim within 90
Under no circumstances will we be held days of the date the Health Care Service was
responsible for, nor will we accept liability rendered or, if it was not reasonably possible to
relating to,the failure of your Group Plan's file within such 90-day period,as soon as
sponsor or plan administrator to: 1)comply with possible. In any event, no Post-Service Claim
any applicable disclosure requirements; will be considered for payment if we do not
2)provide you with a Summary Plan Description receive it at the address indicated on your ID
(SPD); or 3)comply with any other legal Card within one year of the date the Service was
requirements. You should contact your plan rendered unless you were legally incapacitated.
sponsor or administrator if you have questions For Post-Service Claims,we must receive an
relating to your Group Plan's SPD. We are not itemized statement from the health care Provider
your Group Plan's sponsor or plan administrator. for the Service rendered along with a completed
In most cases,a plan's sponsor or plan claim form. The itemized statement must
administrator is the employer who establishes contain the following information:
and maintains the plan. 1. the date the Service was provided;
Types of Claims 2. a description of the Service including any
applicable procedure code(s);
For purposes of this Benefit Booklet,there are
three types of claims: 1)Pre-Service Claims; 3. the amount actually charged by the
2)Post-Service Claims;and 3)Claims Involving Provider;
Urgent Care. It is important that you become 4. the diagnosis including any applicable
familiar with the types of claims that can be diagnosis code(s);
submitted to us and the timeframes and other 5. the Provider's name and address;
requirements that apply.
6. the name of the individual who received the
Service; and
Claims Processing 20-1
7. the Covered Plan Participant's name and claim or a portion of the claim is contested. Our
contract number as they appear on the ID notice may identify: 1)the contested portion or
Card. portions of the claim; 2)the reason(s)for
The itemized statement and claim form must be contesting the claim or a portion of the claim;
received by us at the address indicated on your and 3)the date that we reasonably expect to
ID Card. notify you of the decision. The notice may also
indicate whether additional information is
Note: Special claims processing rules may needed in order to complete processing of the
apply for Health Care Services you receive claim. If we request additional information,we
outside the state of Florida under the BlueCard must receive it within 45 days of our request for
Program (See the"BlueCard(Out-of-State) the information. If we do not receive the
Program"section of this Booklet). requested information,the claim or a portion
The Processinq of Post-Service Claim_s of the claim will be adjudicated based on the
information in our possession at the time
We will use our best efforts to pay, contest, or and may be denied. Upon receipt of the
deny all Post-Service Claims for which we have requested information,we will use our best
all of the necessary information, as determined efforts to complete the processing of the Post-
by us. Post-Service Claims will be paid, Service Claim within 15 days of receipt of the
contested,or denied within the timeframes information.
described below. • Denial of Post-Service Claims
• Payment for Post-Service Claims In the event we deny a Post-Service Claim
When payment is due under the terms of this submitted electronically,we will use our best
Benefit Booklet,we will use our best efforts to efforts to provide notice, within 20 days of
pay(in whole or in part)for electronically receipt,that the claim or a portion of the claim is
submitted Post-Service Claims within 20 days of denied. In the event we deny a paper Post-
receipt. Likewise,we will use our best efforts to Service Claim,we will use our best efforts to
pay(in whole or in part)for paper Post-Service provide notice, within 30 days of receipt,that the
Claims within 40 days of receipt. You may claim or a portion of the claim is denied. The
receive notice of payment for paper claims notice may identify the denied portion(s)of the
within 30 days of receipt. If we are unable to claim and the reason(s)for denial. It is your
determine whether the claim or a portion of the responsibility to ensure that we receive all
claim is payable because we need more or information determined by us as necessary to
additional information,we may contest the claim adjudicate a Post-Service Claim. If we do not
within the timeframes set forth below. receive the necessary information,the claim
or a portion of the claim may be denied.
• Contested Post-Service Claims
A Post-Service Claim denial is an Adverse
In the event we contest an electronically Benefit Determination and is subject to the
submitted Post-Service Claim,or a portion of Adverse Benefit Determination standards and
such a claim,we will use our best efforts to appeal procedures described in this section.
provide notice,within 20 days of receipt,that the
claim or a portion of the claim is contested. In Additional Processing Information for Post-
the event we contest a Post-Service Claim Service Claims
submitted on a paper claim form, or a portion of In any event,we will use our best efforts to pay
such a claim,we will use our best efforts to or deny all: 1)electronic Post-Service Claims
provide notice, within 30 days of receipt, that the within 90 days of receipt of the completed claim;
Claims Processing 20-2
and 2)Post-Service paper claims within 120 Benefit Determinations on Pre-Service Claims
days of receipt of the completed claim. Claims Involving Urgent Care
processing shall be deemed to have been For a Pre-Service Claim Involving Urgent Care,
completed as of the date the notice of the claims we will use our best efforts to provide notice of
decision is deposited in the mail by us or our determination(whether adverse or not)as
otherwise electronically transmitted. Any claims soon as possible, but not later than 72 hours
payment relating to a Post-Service Claim that is after receipt of the Pre-Service Claim unless
not made by us within the applicable timeframe additional information is required for a coverage
is subject to the payment of simple interest at decision. If additional information is necessary
the rate established by the Florida Insurance to make a determination, we will use our best
Code. efforts to provide notice within 24 hours of: 1)
We will investigate any allegation of improper the need for additional information; 2)the
billing by a Provider upon receipt of written specific information that you or your Provider
notification from you. If we determine that you may need to provide; and 3)the date that we
were billed for a Service that was not actually reasonably expect to provide notice of the
performed, any payment amount will be adjusted decision. If we request additional information,
and, if applicable, a refund will be requested. In we must receive it within 48 hours of our
such a case, if payment to the Provider is request. We will use our best efforts to provide
reduced due solely to the notification from you, notice of the decision on your Pre-Service Claim
we will pay you 20 percent of the amount of the within 48 hours after the earlier of: 1)receipt of
reduction, up to a total of$500. the requested information; or 2)the end of the
period you were afforded to provide the
Pre-Service Claims specified additional information as described
above.
How to File a Pre-Service Claim
Benefit Determinations on Pre-Service Claims
This Benefit Booklet may condition coverage, that Do Not Involve Urgent Care
benefits, or payment(in whole or in part),for a
specific Covered Service, on the receipt by us of We will use our best efforts to provide notice of a
decision on aPre-Service Claim not involving
a Pre-Service Claim as that term is defined
herein. In order to determine whether we must urgent care within 15 days of receipt provided
receive a Pre-Service Claim for a particular additional information is not required for a
Covered Service, please refer to the'What Is coverage decision. This 15-day determination
Covered?"section and other applicable sections period may be extended by us one time for up to
of this Benefit Booklet. You may also call the an additional 15 days. If such an extension is
customer service number on your ID card for necessary, we will use our best efforts to provide
assistance. notice of the extension and reasons for it. We
will use our best efforts to provide notification of
We are not required to render an opinion or the decision on your Pre-Service claim within a
make a coverage or benefit determination with total of 30 days of the initial receipt of the claim,
respect to a Service that has not actually been if an extension of time was taken by us.
provided to you unless the terms of this Benefit
Booklet require(or condition payment upon) If additional information is necessary to make a
approval by us for the Service before it is determination, we will use our best efforts to:
1)provide notice of the need for additional
received.
information, prior to the expiration of the initial
15-day period;2)identify the specific information
Claims Processing 20-3
I
that you or your Provider may need to provide; Requests for Extension of Services
and 3)inform you of the date that we reasonably Your Provider may request an extension of
expect to notify you of our decision. If we coverage or benefits for a Service beyond the
request additional information,we must receive approved period of time or number of approved
it within 45 days of our request for the Services. If the request for an extension is for a
information. We will use our best efforts to Claim Involving Urgent Care,we will use our
provide notification of the decision on your Pre- best efforts to notify you of the approval or denial
Service Claim within 15 days of receipt of the of such requested extension within 24 hours
requested information. after receipt of your request, provided it is
A Pre-Service Claim denial is an Adverse received at least 24 hours prior to the expiration
Benefit Determination and is subject to the of the previously approved number or length of
Adverse Benefit Determination standards and coverage for such Services. We will use our
appeal procedures described in this section. best efforts to notify you within 24 hours if: 1)we
need additional information; or 2)you or your
Concurrent Care Decisions representative failed to follow proper procedures
Reduction or Termination of Coverage or in your request for an extension. If we request
Benefits for Services additional information, you will have 48 hours to
provide the requested information.We may
A reduction or termination of coverage or notify you orally or in writing, unless you or your
benefits for Services will be considered an representative specifically request that it be in
Adverse Benefit Determination when: writing. A denial of a request for extension of
• we have approved in writing coverage or Services is considered an Adverse Benefit
benefits for an ongoing course of Services to Determination and is subject to the Adverse
be provided over a period of time or a Benefit Determination review procedure below.
number of Services to be rendered; and
Standards for Adverse Benefit
• the reduction or termination occurs before Determinations
the end of such previously approved time or
number of Services; and Manner and Content of a Notification of an
• the reduction or termination of coverage or Adverse Benefit Determination:
benefits by us was not due to an We will use our best efforts to provide notice of
amendment of this Benefit Booklet or any Adverse Benefit Determination in writing.
termination of your coverage as provided by Notification of an Adverse Benefit Determination
this Benefit Booklet. will include(or will be made available to you free
We will use our best efforts to notify you of such of charge upon request):
reduction or termination in advance so that you 1. the date the Service or supply was provided;
will have a reasonable amount of time to have
the reduction or termination reviewed in 2. the Provider's name;
accordance with the Adverse Benefit 3. the dollar amount of the claim, if applicable;
Determination standards and procedures
described below. In no event shall we be 4. the diagnosis codes included on the claim
required to provide more than a reasonable (e.g., ICD-9, DSM-IV), including a
period of time within which you may develop description of such codes;
your appeal before we actually terminate or 5. the standardized procedure code included
reduce coverage for the Services. on the claim (e.g., Current Procedural
Claims Processing 20-4
Terminology), including a description of such Determination. An appeal of an Adverse Benefit
codes; Determination will be reviewed using the review
6. the specific reason or reasons for the process described below. Your appeal must be
submitted to us in writing for an internal appeal
Adverse Benefit Determination, including within 365 days of the original Adverse Benefit
any applicable denial code; Determination, except in the case of Concurrent
7. a description of the specific Benefit Booklet Care Decisions which may, depending upon the
provisions upon which the Adverse Benefit circumstances, require you to file within a
Determination is based, as well as any shorter period of time from notice of the denial.
internal rule,guideline, protocol, or other The following guidelines are applicable to
similar criterion that was relied upon in reviews of Adverse Benefit Determinations:
making the Adverse Benefit Determination; • We must receive your appeal of an Adverse
8. a description of any additional information Benefit Determination in person or in writing;
that might change the determination and • You may request to review pertinent
why that information is necessary; documents, such as any internal rule,
9. a description of the Adverse Benefit guideline, protocol, or similar criterion relied
upon to make the determination, and submit
Determination review procedures and the issues or comments in writing;
time limits applicable to such procedures;
• If the Adverse Benefit Determination is
10. if the Adverse Benefit Determination is based on the lack of Medical Necessity of a
based on the Medical Necessity or particular Service or the Experimental or
Experimental or Investigational limitations Investigational exclusion, you may request,
and exclusions,a statement telling you how free of charge, an explanation of the
to obtain the specific explanation of the scientific or clinical judgment relied upon, if
scientific or clinical judgment for the any,for the determination,that applies the
determination; and terms of this Benefit Booklet to your medical
circumstances;
11. You have the right to an independent
external review through an external review ' During the review process, the Services in
organization for certain appeals, as provided question will be reviewed without regard to
in the Patient Protection and Affordable the decision reached in the initial
Care Act of 2010. determination;
If the claim is a Claim Involving Urgent Care,we 0 We may consult with appropriate
may notify you orally within the proper Physicians, as necessary;
timeframes, provided we follow-up with a written • Any independent medical consultant who
or electronic notification meeting the reviews your Adverse Benefit Determination
requirements of this subsection no later than on our behalf will be identified upon request;
three days after the oral notification. • If your claim is a Claim Involving Urgent
Care, you may request an expedited appeal
How to Appeal an Adverse Benefit orally or in writing in which case all
Determination necessary information on review may be
transmitted between you and us by
Except as described below, only you, or a telephone,facsimile or other available
representative designated by you in writing, expeditious method; and
have the right to appeal an Adverse Benefit
Claims Processing 20-5
• If you wish to give someone else permission claim denial.The appeal may be directed to an
to appeal an Adverse Benefit Determination employee of BCBSF who is a licensed Physician
on your behalf,we must receive a responsible for Medical Necessity reviews.The
completed Appointment of Representative appeal may be by telephone and the Physician
form signed by you indicating the name of will respond to you,within a reasonable time, not
the person who will represent you with to exceed 15 business days. Requests for an
respect to the appeal. An Appointment of internal appeal should be sent to the address
Representative form is not required if your below:
Physician is appealing an Adverse Benefit
Determination relating to a Claim Involving Blue Cross and Blue Shield of Florida, Inc.
Urgent Care. Appointment of Attention: Member Appeals
Representative forms are available at P.O. Box 44197
www.floridablue.com or by calling the Jacksonville, Florida 32231-4197
number on the back of your BCBSF ID Card.
How to Request External Review of
Timing of Our Appeal Review on Adverse Our Appeal Decision
Benefit Determinations
If you are not satisfied with our internal review of
We will use our best efforts to review your your appeal of an Adverse Benefit
appeal of an Adverse Benefit Determination and Determination, please refer to the Adverse
communicate the decision in accordance with Benefit Determination notice or call the customer
the following time frames: service phone number on your ID Card for
• Pre-Service Claims--within 30 days of the information on how to request an external
receipt of your appeal;or review.
• Post-Service Claims--within 60 days of the Additional Claims Processing
receipt of your appeal;or Provisions
• Claims Involving Urgent Care(and requests
1. Release of Information/Cooperation:
to extend concurrent care Services made
within 24 hours prior to the termination of the In order to process claims,we may need
Services)--within 72 hours of receipt of your certain information, including information
request. If additional information is regarding other health care coverage you
necessary we will notify you within 24 hours may have. You must cooperate with us in
and we must receive the requested our effort to obtain such information by,
additional information within 48 hours of our among other ways, signing any release of
request.After we receive the additional information form at our request. Failure by
information,we will have an additional 48 you to fully cooperate with us may result in a
hours to make a final determination. denial of the pending claim and we will have
Note:The nature of a claim for Services(i.e. no liability for such claim.
whether it is"urgent care"or not)is judged as of 2. Physical Examination:
the time of the benefit determination on review, In order to make coverage and benefit
not as of the time the Service was initially decisions,we may, at our expense, require
reviewed or provided. you to be examined by a health care
You,or a Provider acting on your behalf,who Provider of our choice as often as is
has had a claim denied as not Medically reasonably necessary while a claim is
Necessary has the opportunity to appeal the pending. Failure by you to fully cooperate
Claims Processing 20-6
I
with such examination shall result in a denial c) A description of any additional
of the pending claim and we shall have no information that would change the initial
liability for such claim. determination and why that information
3. Legal Actions: is necessary;
No legal action arising out of or in d) A description of the applicable Adverse
connection with coverage under this Benefit Benefit Determination review
Booklet may be brought against us within procedures and the time limits
the 60-day period following our receipt of the applicable to such procedures; and
completed claim as required herein. e) If the Adverse Benefit Determination is
Additionally, no such action may be brought based on the Medical Necessity or
after expiration of the applicable statute of Experimental or Investigational
limitations. limitations and exclusions, a statement
4. Fraud, Misrepresentation or Omission in telling you how you can obtain the
Applying for Benefits: specific explanation of the scientific or
clinical judgment for the determination.
We rely on the information provided on the
itemized statement and the claim form when 6. Circumstances Beyond Our Control:
processing a claim. All such information, To the extent that natural disaster,war, riot,
therefore, must be accurate,truthful and civil insurrection,epidemic,or other
complete. Any fraudulent statement,
emergency or similar event not within our
omission or concealment of facts, control, results in facilities, personnel or our
misrepresentation,or incorrect information financial resources being unable to process
may result, in addition to any other legal claims for Covered Services,we will have no
remedy we may have, in denial of the claim liability or obligation for any delay in the
or cancellation or rescission of your payment of claims for Covered Services,
coverage. except that we will make a good faith effort
5. Explanation of Benefits Form: to make payment for such Services,taking
All claims decisions, including denial and into account the impact of the event. For the
claims review decisions,will be purposes of this paragraph, an event is not
communicated to you in writing either on an within our control if we cannot effectively
explanation of benefits form or some other exercise influence or dominion over its
written correspondence.This form may occurrence or non-occurrence.
indicate:
a) The specific reason or reasons for the
Adverse Benefit Determination;
b) Reference to the specific Benefit
Booklet provisions upon which the
Adverse Benefit Determination is based
as well as any internal rule, guideline,
protocol,or other similar criterion that
was relied upon in making the Adverse
Benefit Determination;
Claims Processing 20-7
Section 21 : Relationship Between the Parties
BCBSF/Monroe County BOCC and nor Monroe County BOCC will be liable,whether
Health Care Providers in tort or contract or otherwise,for any acts or
omissions of any other person or organization
Neither BCBSF nor Monroe County BOCC nor with which BCBSF has made or hereafter makes
any of their officers, directors or employees arrangements for the provision of Covered
provides Health Care Services to you. Rather, Services. BCBSF is not your agent, servant,or
BCBSF and Monroe County BOCC are engaged representative nor is BCBSF an agent, servant,
in making coverage and benefit decisions under or representative of Monroe County BOCC and
this Booklet. By accepting the Group health BCBSF will not be liable for any acts or
care coverage and benefits,you agree that omissions, or those of Monroe County BOCC, its
making such coverage and benefit decisions agents, servants,employees, or any person or
does not constitute the rendering of Health Care organization with which Monroe County BOCC
Services and that health care Providers has entered into any agreement or arrangement.
rendering those Services are not employees or By acceptance of coverage and benefits
agents of BCBSF or Monroe County BOCC. In hereunder, you agree to the foregoing.
this regard,we and Monroe County BOCC
hereby expressly disclaim any agency Medical Treatment Decisions-
relationship,actual or implied,with any Responsibility of Your Physician, Not
health care Provider. BCBSF and Monroe BCBSF
County BOCC do not, by virtue of making
coverage, benefit, and payment decisions, Any and all decisions that require or pertain to
exercise any control or direction over the independent professional medical judgment or
medical judgment or clinical decisions of any training, or the need for medical Services or
health care Provider. Any decisions made under supplies, must be made solely by your family
the Group Health Plan concerning and your treating Physician in accordance with
appropriateness of setting, or whether any the patient/physician relationship. It is possible
Service is Medically Necessary, shall be that you or your treating Physician may conclude
deemed to be made solely for purposes of that a particular procedure is needed,
determining whether such Services are covered, appropriate,or desirable, even though such
and not for purposes of recommending any procedure may not be covered.
treatment or non-treatment. Neither BCBSF nor
Monroe County BOCC will assume liability for
any loss or damage arising as a result of acts or
omissions of any health care Provider.
Non Liability of BCBSF and Monroe
County BOCC
Neither Monroe County BOCC nor any person
covered under this Booklet is BCBSF's agent or
representative, and neither shall be liable for any
acts or omissions by BCBSF's agents,servants,
employees, or us. Additionally, neither BCBSF
Relationship Between the Parties 21-1
Section 22: General Provisions
Access to Information Compliance with State and Federal
Laws and Regulations
BCBSF and Monroe County BOCC have the
right to receive,from you and any health care The terms of coverage and benefits to be
Provider rendering Services to you, information provided under this Benefit Booklet shall be
that is reasonably necessary, as determined by deemed to have been modified and shall be
BCBSF and Monroe County BOCC, in order to interpreted, so as to comply with applicable state
administer the coverage and benefits provided, or federal laws and regulations dealing with
subject to all applicable confidentiality benefits, eligibility, enrollment,termination, or
requirements listed below. By accepting other rights and duties.
coverage, you authorize every health care
Provider who renders Services to you,to Confidentiality
disclose to BCBSF and Monroe County BOCC Except as otherwise specifically provided herein,
or to affiliated entities, upon request, all facts, and except as may be required in order for us to
records, and reports pertaining to your care, administer coverage and benefits, specific
treatment, and physical or mental Condition, and medical information concerning you, received by
to permit BCBSF and/or Monroe County BOCC Providers, shall be kept confidential by us in
to copy any such records and reports so conformity with applicable law. Such information
obtained. may be disclosed to third parties for use in
connection with bona fide medical research and
Right to Receive Necessary education,or as reasonably necessary in
Information connection with the administration of coverage
and benefits, specifically including BCBSF's
In order to administer coverage and benefits, quality assurance and Blueprint for Health
BCBSF or Monroe County BOCC may,without Programs. Additionally, we may disclose such
the consent of,or notice to,any person, plan, or information to entities affiliated with us or other
organization, obtain from any person, plan, or persons or entities we utilize to assist in
organization any information with respect to any providing coverage, benefits or services under
person covered under this Booklet or applicant this Booklet. Further, any documents or
for enrollment which BCBSF or Monroe County information which are properly subpoenaed in a
BOCC deem to be necessary. judicial proceeding, or by order of a regulatory
agency, shall not be subject to this provision.
Right to Recovery BCBSF's arrangements with a Provider may
require that we release certain claims and
Whenever the Group Health Plan has made medical information about persons covered
payments in excess of the maximum provided under this Booklet to that Provider even if
for under this Booklet, BCBSF or Monroe treatment has not been sought by or through
County BOCC will have the right to recover any that Provider. By accepting coverage, you
such payments,to the extent of such excess, hereby authorize us to release to Providers
from you or any person, plan, or other claims information, including related medical
organization that received such payments. information, pertaining to you in order for any
such Provider to evaluate your financial
responsibility under this Booklet.
General Provisions 22-1
Benefit Booklet constitute a waiver of any such terms or
conditions. Further, it will not affect BCBSF's or
You have been provided with this Benefit Monroe County BOCC's right at any time to
Booklet and an Identification Card as evidence enforce any terms or conditions under this
of your coverage under this Benefit Booklet. Benefit Booklet.
Modification of Provider Network and Notices
the Participation Status
Any notice required or permitted hereunder will
NetworkBlue and the Traditional Provider be deemed given if hand delivered or if mailed
Program, and the participation status of by United States Mail, postage prepaid, and
individual Providers available through BCBSF, addressed as listed below. Such notice will be
are subject to change at any time by BCBSF deemed effective as of the date delivered or so
without prior notice to you or your approval or deposited in the mail.
that of Monroe County BOCC. Additionally,
If to BCBSF:
BCBSF may,at any time,terminate or modify
the terms of any Provider contract and may To the address printed on the Identification
enter into additional Provider contracts without Card.
prior notice to you, or your approval or that of If to you:
Monroe County BOCC. It is your responsibility
to determine whether a health care Provider is To the latest address provided by you or to
an In-Network Provider at the time the Health your latest address on Enrollment Forms
Care Service is rendered. Under this Booklet, actually delivered to us.
your financial responsibility may vary depending You must notify Monroe County BOCC
upon a Provider's participation status. Benefits Office immediately of any
Cooperation Required of You and address change.
Your Covered Dependents If to Monroe County BOCC:
To the address indicated by Monroe County
You must cooperate with BCBSF and Monroe BOCC.
County BOCC, and must execute and submit to
us any consents, releases, assignments, and Our Obligations Upon Termination
other documents requested in order to
administer, and exercise any rights hereunder. Upon termination of your coverage for any
Failure to do so may result in the denial of reason,there will be no further liability or
claims and will constitute grounds for termination responsibility to you under the Group Health
for cause(See the Termination of an Individual's Plan, except as specifically described herein.
Coverage for Cause subsection in the
Termination Of Coverage section). Promissory Estoppel
Non-Waiver of Defaults No oral statements, representations,or
understanding by any person can change, alter,
Any failure by BCBSF or Monroe County BOCC delete,add, or otherwise modify the express
at any time, or from time to time,to enforce or to written terms of this Booklet.
require the strict adherence to any of the terms
or conditions described herein, will in no event
General Provisions yy_y
Florida Agency for Health Care
Administration Performance Data
The performance outcome and financial data
published by the Agency for Health Care
Administration(AHCA), pursuant to Florida
Statute 408.05, or any successor statute,
located at the web site address
www.floridahealthfinder.gov, may be accessed
through the link provided on the Blue Cross and
Blue Shield of Florida corporate web site at
www.floridablue.com.
Third Party Beneficiary
The terms and provisions of the Group Health
Plan shall be binding solely upon, and inure
solely to the benefit of, Monroe County BOCC
and individuals covered under the terms of this
Benefit Booklet,and no other person shall have
any rights, interest or claims thereunder, or
under this Benefit Booklet, or be entitled to sue
for a breach thereof as a third-party beneficiary
or otherwise. Monroe County BOCC hereby
specifically expresses its intent that health care
Providers that have not entered into contracts
with BCBSF to participate in BCBSF's Provider
networks shall not be third-party beneficiaries
under the terms of the Monroe County BOCC
Group Health Plan or this Benefit Booklet.
Customer Rewards Programs
From time to time,we may offer programs to our
customers that provide rewards for following the
terms of the program. We will tell you about any
available rewards programs in general mailings,
member newsletters and/or on our website.
Your participation in these programs is
completely voluntary and will in no way affect
the coverage available to you under this Benefit
Booklet. We reserve the right to offer rewards in
excess of$25 per year as well as the right to
discontinue or modify any reward program
features or promotional offers at any time
without your consent.
General Provisions 22-3
Section 23: Definitions
The following definitions are used in this Benefit 1. In the case of an In-Network Provider
Booklet. Other definitions may be found in the located in Florida,this amount will be
particular section or subsection where they are established in accordance with the
used. applicable agreement between that Provider
Accident means an unintentional, unexpected and BCBSF.
event, other than the acute onset of a bodily 2. In the case of an In-Network Provider
infirmity or disease,which results in traumatic located outside of Florida,this amount will
injury. This term does not include injuries generally be established in accordance with
caused by surgery or treatment for disease or the negotiated price that the on-site Blue
illness. Cross and/or Blue Shield Plan("Host Blue")
passes on to us, except when the Host Blue
Accidental Dental Injury means an injury to is unable to pass on its negotiated price due
sound natural teeth(not previously to the terms of its Provider contracts. See
compromised by decay)caused by a sudden, the BlueCard(Out-of-State)Program
unintentional,and unexpected event or force. section for more details.
This term does not include injuries to the mouth, 3. In the case of Out-of-Network Providers
structures within the oral cavity,or injuries to located in Florida who participate in the
natural teeth caused by biting or chewing,
surgery, or treatment for a disease or illness. Traditional Program,this amount will be
established in accordance with the
Administrative Services Only Agreement or applicable agreement between that Provider
ASO Agreement means an agreement between and BCBSF.
Monroe County BOCC and BCBSF. Under the 4. In the case of Out-of-Network Providers
Administrative Services Only Agreement, located outside of Florida who participate in
BCBSF provides claims processing and the BlueCard(Out-of-State)Traditional
payment services,customer service, utilization Program,this amount will generally be
review services and access to BCBSF's established in accordance with the
NetworkBlue and BCBSF's network of
negotiated pace that the Host Blue passes
Traditional Insurance Providers. on to us, except when the Host Blue is
Adverse Benefit Determination means any unable to pass on its negotiated price due to
denial, reduction or termination of coverage, the terms of its Provider contracts. See the
benefits, or payment(in whole or in part)under BlueCard (Out-of-State) Program section for
the Benefit Booklet with respect to a Pre-Service more details.
Claim or a Post-Service Claim.Any reduction or 5. In the case of an Out-of-Network Provider
termination of coverage, benefits, or payment in that has not entered into an agreement with
connection with a Concurrent Care Decision, as BCBSF to provide access to a discount from
described in this section, shall also constitute an the billed amount of that Provider for the
Adverse Benefit Determination. specific Covered Services provided to you,
Allowed Amount means the maximum amount the Allowed Amount will be the lesser of that
upon which payment will be based for Covered Provider's actual billed amount for the
Services. The Allowed Amount may be changed specific Covered Services or an amount
at any time without notice to you or your established by BCBSF that may be based
consent. on several factors including (but not
DefirnGons 23-1
i
necessarily limited to): (i)payment for such billed by such Out-of-Network Provider for such
Services under the Medicare and/or Services. You will be responsible for any
Medicaid programs; (ii)payment often difference between such Allowed Amount and
accepted for such Services by that Out-of- the amount billed for such Services by any such
Network Provider and/or by other Providers, Out-of-Network Provider.
either in Florida or in other comparable Ambulance means a ground or water vehicle,
market(s),that BCBSF determines are airplane or helicopter properly licensed pursuant
comparable to the Out-of-Network Provider to Chapter 401 of the Florida Statutes, or a
that provided the specific Covered Services similar applicable law in another state.
(which may include payment accepted by Ambulatory Surgical Center means a facility
such Out-of-Network Provider and/or by
other Providers as participating providers in properly licensed pursuant to Chapter 395 of the
Florida Statutes, or a similar applicable law of
other provider networks of third-party payers another state,the primary purpose of which is to
which may include,for example, other provide elective surgical care to a patient,
insurance companies and/or health admitted to, and discharged from such facility
maintenance organizations); (iii)payment within the same working day.
amounts which are consistent, as
determined by BCBSF,with BCBSF's Applied Behavior Analysis means the design,
provider network strategies(e.g., does not implementation and evaluation of environmental
result in payment that encourages Providers modifications, using behavioral stimuli and
participating in a BCBSF network to become consequences to produce socially significant
improvement in human behavior, including, but
non-participating); and/or, (iv)the cost of not limited to,the use of direct observation,
providing the specific Covered Services. In measurement and functional analysis of the
the case of an Out-of-Network Provider that relations between environment and behavior.
has not entered into an agreement with
another Blue Cross and/or Blue Shield Artificial Insemination (Al)means a medical
organization to provide access to discounts procedure in which sperm is placed into the
from the billed amount for the specific female reproductive tract by a qualified health
Covered Services under the BlueCard(Out- care provider for the purpose of producing a
of-State)Program,the Allowed Amount for pregnancy.
the specific Covered Services provided to Autism Spectrum Disorder means any of the
you may be based upon the amount following disorders as defined in the diagnostic
provided to BCBSF by the other Blue Cross categories of the International Classification of
and/or Blue Shield organization where the Diseases, Ninth Edition, Clinical Modification
Services were provided at the amount such (ICD-9 CM), or their equivalents in the most
organization would pay non-participating recently published version of the American
Providers in its geographic area for such Psychiatric Association's Diagnostic and
Services. Statistical Manual of Mental Disorders:
Please specifically note that, in the case of an 1. Autistic disorder;
Out-of-Network Provider that has not entered 2. Asperger's syndrome;
into an agreement with BCBSF to provide
access to a discount from the billed amount of 3. Pervasive developmental disorder not
that Provider,the Allowed Amount for particular otherwise specified; and
Services is often substantially below the amount 4. Childhood Disintegrative Disorder.
Definitions 23-2
Benefit Period means a consecutive period of BlueCard (Out-of-State) PPO Program
time, specified by BCBSF and the Group, in Provider means a Provider designated as a
which benefits accumulate toward the BlueCard(Out-of-State) PPO Program Provider
satisfaction of Deductibles, out-of-pocket by the Host Blue.
maximums and any applicable benefit
maximums. Your Benefit Period is listed on your BlueCard (Out-of-State)Traditional Program
Schedule of Benefits,and will not be less than Provider means a Provider designated as a
12 months unless indicated as such. BlueCard(Out-of-State)Traditional Program
Provider by the Host Blue.
Birth Center means a facility or institution, other
than a Hospital or Ambulatory Surgical Center, Bone Marrow Transplant means human blood
which is properly licensed pursuant to Chapter Precursor cells administered to a patient to
383 of the Florida Statutes, or a similar restore normal hematological and immunological
applicable law of another state, in which births functions following ablative or non-ablative
are planned to occur away from the mother's therapy with curative or life-prolonging intent.
usual residence following a normal, Human blood precursor cells may be obtained
uncomplicated, low-risk pregnancy. from the patient in an autologous transplant, or
an allogeneic transplant from a medically
BlueCard(Out-of-State) Program means a acceptable related or unrelated donor, and may
national Blue Cross and Blue Shield Association be derived from bone marrow,the circulating
program available through Blue Cross and Blue blood, or a combination of bone marrow and
Shield of Florida, Inc. Subject to any applicable circulating blood. If chemotherapy is an integral
BlueCard(Out-of-State)Program rules and part of the treatment involving bone marrow
protocols, you may have access to the Provider transplantation,the term "Bone Marrow
discounts of other participating Blue Cross and/or Transplant"includes the transplantation as well
Blue Shield plans. See the BlueCard(Out-of- as the administration of chemotherapy and the
State)Program section for more details. chemotherapy drugs. The term "Bone Marrow
BlueCard(Out-of-State) PPO Program means Transplant"also includes any Services or
supplies relating to any treatment or therapy
a national Blue Cross and Blue Shield involving the use of high dose or intensive dose
Association program available through Blue chemotherapy and human blood precursor cells
Cross and Blue Shield of Florida, Inc. Subject to and includes any and all Hospital, Physician or
any applicable BlueCard(Out-of-State) Program other health care Provider Health Care Services
rules and protocols, you may have access to the which are rendered in order to treat the effects
BlueCard(Out-of-State) PPO Program discounts of,or complications arising from, the use of high
of other participating Blue Cross and/or Blue dose or intensive dose chemotherapy or human
Shield plans.
blood precursor cells(e.g., Hospital room and
BlueCard (Out-of-State)Traditional Program board and ancillary Services).
means a national Blue Cross and Blue Shield Calendar Year begins January 1 st and ends
Association program available through Blue December 31st.
Cross and Blue Shield of Florida, Inc. Subject to
any applicable BlueCard(Out-of-State)Program Cardiac Therapy means Health Care Services
rules and protocols, you may have access to the provided under the supervision of a Physician,
BlueCard(Out-of-State)Traditional Program or an appropriate Provider trained for Cardiac
discounts of other participating Blue Cross Therapy,for the purpose of aiding in the
and/or Blue Shield plans. restoration of normal heart function in
Defindions 23-3
connection with a myocardial infarction, As defined herein, a Concurrent Care Decision
coronary occlusion or coronary bypass surgery. shall not include any decision to deny, reduce,
or terminate coverage, benefits, or payment
Certified Nurse Midwife means a person who under the personal case management Program
is licensed pursuant to Chapter 464 of the as described in the as For Health
Florida Statutes,or a similar applicable law of Programs'section of this Benefit Booklet. �
another state,as an advanced nurse practitioner
and who is certified to practice midwifery by the Condition means a disease, illness,ailment,
American College of Nurse Midwives. injury, or pregnancy.
Certified Registered Nurse Anesthetist Convenient Care Center means a properly
means a person who is a properly licensed licensed ambulatory center that: 1)treats a
nurse who is a certified advanced registered limited number of common,low-intensity
nurse practitioner within the nurse anesthetist illnesses when ready access to the patient's
category pursuant to Chapter 464 of the Florida primary physician is not possible; 2)shares
Statutes,or a similar applicable law of another clinical information about the treatment with the
state. patient's primary physician;3)is usually housed
in a retail business;and 4) is staffed by at least
Claim Involving Urgent Care means any one master's level nurse(ARNP)who operates
request or application for coverage or benefits under a set of clinical protocols that strictly
for medical care or treatment that has not yet circumscribe the conditions the ARNP can treat.
been provided to you with respect to which the Although no physician is present at the
application of time periods for making non- Convenient Care Center, medical oversight is
urgent care benefit determinations:(1)could based on a written collaborative agreement
seriously jeopardize your life or health or your between a supervising physician and the ARNP.
ability regain ain maximum function; or(2)in the
9
opinion of a Physician with knowledge of your Copayment means the dollar amount
Condition,would subject you to severe pain that established solely by BCBSF and Monroe
cannot be adequately managed without the County BOCC which is required to be paid to a
proposed Services being rendered. health care Provider by you at the time certain
Coinsurance means your share of health care Covered Services are rendered by that Provider.
expenses for Covered Services. After your Cost Share means the dollar or percentage
Deductible requirement is met, a percentage of amount established solely by us,which must be
the Allowed Amount will be paid for Covered paid to a health care Provider by you at the time
Services, as listed in the Schedule of Benefits. Covered Services are rendered by that Provider.
The percentage you are responsible for is your Cost Share may include, but is not limited to
Coinsurance. Coinsurance, Copayment, Deductible and/or Per
Admission Deductible(PAD)amounts.
Concurrent Care Decision means a decision Applicable Cost Share amounts are identified in
by us to deny, reduce, or terminate coverage, your Schedule of Benefits.
benefits, or payment(in whole or in part)with
respect to a course of treatment to be provided Covered Dependent means an Eligible
over a period of time,or a specific number of Dependent who meets and continues to meet all
treatments,if we had previously approved or applicable eligibility requirements and who is
authorized in writing coverage, benefits, or enrolled, and actually covered, under the Group
payment for that course of treatment or number Health Plan other than as a Covered Plan
of treatments. Participant(See the"Eligibility Requirements for
Definitions 23-4
Dependent(s)"subsection of the"Eligibility for metabolic or other means,the intoxicating
Coverage"section). alcohol or drug,alcohol or drug dependent
factors or alcohol in combination with drugs as
Covered Person means a Covered Plan determined by a licensed Physician or
Participant or a Covered Dependent. Psychologist, while keeping the physiological
Covered Plan Participant means an Eligible risk to the individual at a minimum.
Employee or other individual who meets and Diabetes Educator means a person who is
continues to meet all applicable eligibility properly certified pursuant to Florida law, or a
requirements and who is enrolled, and actually similar applicable law of another state,to
covered, under this Benefit Booklet other than supervise diabetes outpatient self-management
as a Covered Dependent. training and educational services.
Covered Services means those Health Care Dialysis Center means an outpatient facility
Services which meet the criteria listed in the certified by the Centers for Medicare and
"What Is Covered?"section. Medicaid Services(CMMS)and the Florida
Custodial or Custodial Care means care that Agency for Health Care Administration(or a
serves to assist an individual in the activities of similar regulatory agency of another state)to
daily living, such as assistance in walking, provide hemodialysis and peritoneal dialysis
getting in and out of bed, bathing, dressing, services and support.
feeding, and using the toilet, preparation of Dietitian means a person who is properly
special diets,and supervision of medication that licensed pursuant to Florida law or a similar
usually can be self-administered. Custodial applicable law of another state to provide
Care essentially is personal care that does not nutrition counseling for diabetes outpatient self-
require the continuing attention of trained management services.
medical or paramedical personnel. In
determining whether a person is receiving Durable Medical Equipment means equipment
Custodial Care, consideration is given to the furnished by a supplier or a Home Health
frequency, intensity and level of care and Agency that: 1)can withstand repeated use;
medical supervision required and furnished. A 2)is primarily and customarily used to serve a
determination that care received is Custodial is medical purpose; 3)not for comfort or
not based on the patient's diagnosis,type of convenience; 4)generally is not useful to an
Condition, degree of functional limitation,or individual in the absence of a Condition; and
rehabilitation potential. 5)is appropriate for use in the home.
Deductible means the amount of charges, up to Durable Medical Equipment Provider means a
the Allowed Amount,for Covered Services that person or entity that is properly licensed, if
are your responsibility. The term, Deductible, applicable, under Florida law(or a similar
does not include any amounts you are applicable law of another state)to provide home
responsible for in excess of the Allowed Amount, medical equipment,oxygen therapy services, or
or any Coinsurance/Copay amounts, if dialysis supplies in the patient's home under a
applicable. Physician's prescription.
Detoxification means a process whereby an Effective Date means,with respect to
alcohol or drug intoxicated, or alcohol or drug individuals covered under this Benefit Booklet,
dependent, individual is assisted through the 12:01 a.m. on the date Monroe County BOCC
period of time necessary to eliminate, by specifies that the coverage will commence as
Defirnfions 23-5
further described in the"Enrollment and 2. within the capabilities of the staff and
Effective Date of Coverage"section of this facilities available at the hospital, such
Benefit Booklet. further medical examination and treatment
I
Eligible Dependent means an individual who as are required under Section 1867 of such
meets and continues to meet all of the eligibility Act to Stabilize the patient.
requirements described in the Eligibility Endorsement means an amendment to the
Requirements for Dependent(s)subsection of Group Health Plan or this Booklet.
the Eligibility for Coverage section in this Benefit
Booklet, and is eligible to enroll as a Covered Enrollment Date means the date of enrollment
Dependent. of the individual under the Group Health Plan or,
if earlier,the first day of the Waiting Period of
Eligible Employee means an active employee such enrollment.
or retiree who meets and continues to meet all
of the eligibility requirements described in the Enrollment Forms means those forms,
Eligibility Requirements for Covered Plan electronic(where available)or paper,which are
Participant subsection of the Eligibility for used to maintain accurate enrollment files under
Coverage section in the Benefit Booklet and is this Benefit Booklet.
eligible to enroll as a Covered Plan Participant. Experimental or Investigational means any
Any individual who is an Eligible Employee is not evaluation,treatment,therapy, or device which
a Covered Plan Participant until such individual involves the application, administration or use, of
has actually enrolled with, and been accepted procedures,techniques, equipment, supplies,
for coverage as a Covered Plan Participant by products, remedies, vaccines, biological
Monroe County BOCC.
products, drugs, pharmaceuticals,or chemical
Emergency Medical Condition means a compounds if, as determined solely by BCBSF:
medical or psychiatric Condition or an injury 1. such evaluation, treatment, therapy, or
manifesting itself by acute symptoms of device cannot be lawfully marketed without
sufficient severity(including severe pain)such approval of the United States Food and
that a prudent layperson,who possesses an Drug Administration or the Florida
average knowledge of health and medicine, Department of Health and approval for
could reasonably expect the absence of marketing has not, in fact, been given at the
immediate medical attention to result in a time such is furnished to you;or
condition described in clause(i),(ii), or(iii)of
Section 1867(e)(1)(A)of the Social Security Act. 2. such evaluation,treatment,therapy, or
device is provided pursuant to a written
Emergency Services means, with respect to an protocol which describes as among its
I
Emergency Medical Condition: objectives the following: determinations of
1. a medical screening examination (as safety, efficacy, or efficacy in comparison to
required under Section 1867 of the Social
the standard evaluation,treatment,therapy,
Security Act)that is within the capability of or device; or
the emergency department of a Hospital, 3. such evaluation,treatment, therapy, or
including ancillary Services routinely device is delivered or should be delivered
available to the emergency department to subject to the approval and supervision of
evaluate such Emergency Medical an institutional review board or other entity
Condition; and as required and defined by federal
regulations;or
Definitions 23-6
4. credible scientific evidence shows that such 2. reports, articles, or written assessments in
evaluation,treatment,therapy,or device is authoritative medical and scientific literature
the subject of an ongoing Phase I or II published in the United States, Canada, or
clinical investigation,or the experimental or Great Britain;
research arm of a Phase III clinical 3. published reports,articles, or other literature
investigation, or under study to determine: of the United States Department of Health
maximum tolerated dosage(s),toxicity, and Human Services or the United States
safety, efficacy, or efficacy as compared Public Health Service, including any of the
with the standard means for treatment or National Institutes of Health, or the United
diagnosis of the Condition in question;or States Office of Technology Assessment;
5. credible scientific evidence shows that the
4. the written protocol or protocols relied upon
consensus of opinion among experts is that by the treating Physician or institution or the
further studies, research, or clinical protocols of another Physician or institution
investigations are necessary to determine: studying substantially the same evaluation,
maximum tolerated dosage(s),toxicity, treatment, therapy, or device;
safety, efficacy, or efficacy as compared
with the standard means for treatment or 5. the written informed consent used by the
diagnosis of the Condition in question; or treating Physician or institution or by another
Physician or institution studying substantially
6. credible scientific evidence shows that such the same evaluation,treatment,therapy, or
evaluation,treatment, therapy, or device has
device; or
not been proven safe and effective for
treatment of the Condition in question,as 6. the records(including any reports)of any
evidenced in the most recently published institutional review board of any institution
Medical Literature in the United States, which has reviewed the evaluation,
Canada, or Great Britain, using generally treatment,therapy, or device for the
accepted scientific, medical,or public health Condition in question.
methodologies or statistical practices; or Note: Health Care Services which are
7. there is no consensus among practicing determined by BCBSF to be Experimental or
Physicians that the treatment,therapy, or Investigational are excluded(see the"What
device is safe and effective for the Condition Is Not Covered?"section). In determining
in question; or whether a Health Care Service is
Experimental or Investigational, BCBSF may
8. such evaluation, treatment,therapy, or also rely on the predominant opinion among
device is not the standard treatment, experts, as expressed in the published
therapy, or device utilized by practicing authoritative literature,that usage of a
Physicians in treating other patients with the
particular evaluation,treatment,therapy, or
same or similar Condition. device should be substantially confined to
"Credible scientific evidence"shall mean(as research settings or that further studies are
determined by BCBSF): necessary in order to define safety,toxicity,
1. records maintained by Physicians or effectiveness,or effectiveness compared
Hospitals rendering care or treatment to you with standard alternatives.
or other patients with the same or similar FDA means the United States Food and Drug
Condition; Administration.
DefirnUons 23-7
Foster Child means a person who is placed in Health Care Services or Services includes
your residence and care under the Foster Care treatments,therapies, devices, procedures,
Program by the Florida Department of Health& techniques,equipment, supplies, products,
Rehabilitative Services in compliance with remedies,vaccines, biological products, drugs,
Florida Statutes or by a similar regulatory pharmaceuticals,chemical compounds, and
agency of another state in compliance with that other services rendered or supplied, by or at the
state's applicable laws. direction of, Providers.
Gamete Intrafallopian Transfer(GIFT)means Home Health Agency means a properly
the direct transfer of a mixture of sperm and licensed agency or organization which provides
eggs into the fallopian tube by a qualified health health services in the home pursuant to Chapter
care provider. Fertilization takes place inside 400 of the Florida Statutes, or a similar
the tube. applicable law of another state.
Generally Accepted Standards of Medical Home Health Care or Home Health Care
Practice means standards that are based on Services means Physician-directed
credible scientific evidence published in peer- professional, technical and related medical and
reviewed medical literature generally recognized personal care Services provided on an
by the relevant medical community, Physician intermittent or part-time basis directly by(or
Specialty Society recommendations, and the indirectly through)a Home Health Agency in
views of Physicians practicing in relevant clinical your home or residence. For purposes of this
areas and any other relevant factors. definition, a Hospital, Skilled Nursing Facility,
Gestational Surrogate means a woman, nursing home or other facility will not be
regardless of age,who contracts,orally or in considered an individual's home or residence.
writing,to become pregnant by means of Hospice means a public agency or private
assisted reproductive technology without the use organization which is duly licensed by the State
of an egg from her body. of Florida under applicable law, or a similar
Gestational Surrogacy Contract or applicable law of another state,to provide
Arrangement means an oral or written hospice services. In addition,such licensed
agreement, regardless of the state or jurisdiction entity must be principally engaged in providing
where executed, between the Gestational pain relief, symptom management,and
Surrogate and the intended parent or parents. supportive services to terminally ill persons and
their families.
Group means the employer, labor union,trust,
association, partnership,or corporation, Hospital means a facility properly licensed
department, other organization or entity through Pursuant to Chapter 395 of the Florida Statutes,
which coverage and benefits under this Benefit or a similar applicable law of another state,that:
Booklet are made available to you, and through offers services which are more intensive than
those required for room, board, personal
which you and your Covered Dependents
become entitled to coverage and benefits for the services and general nursing care;offers
Covered Services described herein. facilities and beds for use beyond 24 hours;and
regularly makes available at least clinical
Group Health Plan or Group Plan means the laboratory services, diagnostic x-ray services
plan established and maintained by Monroe and treatment facilities for surgery or obstetrical
County BOCC for the provision of health care care or other definitive medical treatment of
coverage and benefits to the individuals covered similar extent.
under this Benefit Booklet.
Definitions 23-8
The term Hospital does not include: an performed by a licensed Physician or by
Ambulatory Surgical Center;a Skilled Nursing licensed, certified non-Physician personnel
Facility;a stand-alone Birthing Center; a under appropriate Physician supervision. An
Psychiatric Facility;a Substance Abuse Facility; Independent Diagnostic Testing Facility must be
a convalescent, rest or nursing home;or a appropriately registered with the Agency for
facility which primarily provides Custodial, Health Care Administration and must comply
educational, or Rehabilitative Therapies. with all applicable Florida law or laws of the
State in which it operates. Further, such an
Note: if services specifically for the entity must meet BCBSF's criteria for eligibility
treatment of a physical disability are as an Independent Diagnostic Testing Facility.
provided in a licensed Hospital which is
accredited by the Joint Commission on the In-Network means,when used in reference to
Accreditation of Health Care Organizations, Covered Services,the level of benefits payable
the American Osteopathic Association, or to an In-Network Provider as designated on the
the Commission on the Accreditation of Schedule of Benefits under the heading"In-
Rehabilitative Facilities, payment for these Network". Otherwise, In-Network means,when
services will not be denied solely because used in reference to a Provider,that, at the time
such Hospital lacks major surgical facilities Covered Services are rendered, the Provider is
and is primarily of a rehabilitative nature. an In-Network Provider under the terms of this
Recognition of these facilities does not Booklet.
expand the scope of Covered Services. It In-Network Provider means any health care
only expands the setting where Covered Provider who, at the time Covered Services
Services can be performed for coverage were rendered to you, was under contract with
purposes. BCBSF to participate in BCBSF's NetworkBlue
Identification(ID)Card means the card(s) and included in the panel of providers
issued to Covered Plan Participants under the designated by BCBSF as"In-Network"for your
BlueOptions Group Health Plan. The card is not specific plan. (Please refer to your Schedule of
transferable to another person. Possession of Benefits). For payment purposes under this
such card in no way guarantees that a particular Benefit Booklet only,the term In-Network
individual is eligible for,or covered under,this Provider also refers,when applicable, to any
Benefit Booklet. health care Provider located outside the state of
Florida who or which, at the time Health Care
Independent Clinical Laboratory means a Services were rendered to you, participated as a
laboratory properly licensed pursuant to Chapter BlueCard (Out-of-State)PPO Program Provider
483 of the Florida Statutes, or a similar under the Blue Cross Blue Shield Association's
applicable law of another state, where BlueCard(Out-of-State) Program.
examinations are performed on materials or
specimens taken from the human body to In Vitro Fertilization(IVF) means a process in
provide information or materials used in the which an egg and sperm are combined in a
diagnosis, prevention, or treatment of a laboratory dish to facilitate fertilization. If
Condition. fertilized, the resulting embryo is transferred to
the woman's uterus.
Independent Diagnostic Testing Facility
means a facility, independent of a Hospital or Licensed Practical Nurse means a person
Physician's office,which is a fixed location, a properly licensed to practice practical nursing
mobile entity, or an individual non-Physician pursuant to Chapter 464 of the Florida Statues,
practitioner where diagnostic tests are or a similar applicable law of another state.
Defintbons 23.9
Massage Therapist means a person properly Service or sequence of Services at least as
licensed to practice Massage, pursuant to likely to produce equivalent therapeutic or
Chapter 480 of the Florida Statutes, or a similar diagnostic results as to the diagnosis or
applicable law of another state. treatment of your illness.
Massage or Massage Therapy means the Note: It is important to remember that any
manipulation of superficial tissues of the human review of Medical Necessity by us is solely for
body using the hand,foot, arm, or elbow. For the purpose of determining coverage or benefits
purposes of this Benefit Booklet,the term under this Booklet and not for the purpose of
Massage or Massage Therapy does not include recommending or providing medical care. In this
the application or use of the following or similar respect,we may review specific medical facts or
techniques or items for the purpose of aiding in information pertaining to you. Any such review,
the manipulation of superficial tissues: hot or however, is strictly for the purpose of
cold packs;hydrotherapy; colonic irrigation; determining, among other things,whether a
thermal therapy;chemical or herbal Service provided or proposed meets the
preparations; paraffin baths; infrared light; definition of Medical Necessity in this Booklet as
ultraviolet light; Hubbard tank; or contrast baths. determined by us. In applying the definition of
Medical Necessity in this Booklet,we may apply
Mastectomy means the removal of all or part of our coverage and payment guidelines then in
the breast for Medically Necessary reasons as effect. You are free to obtain a Service even if
determined by a Physician. we deny coverage because the Service is not
Medical Literature means scientific studies Medically Necessary; however, you will be solely
published in a United States peer-reviewed responsible for paying for the Service.
national professional journal.
Medicare means the federal health insurance
Medical Pharmacy means Physician- provided under Title XVIII of the Social Security
administered Prescription Drugs which are Act and all amendments thereto.
rendered in a Physician's office. Medication Guide for the purpose of this
Medically Necessary or Medical Necessity Benefit Booklet means the guide then in effect
means that, with respect to a Health Care issued by us where you may find information
Service, a Physician,exercising prudent clinical about Specialty Drugs, Prescription Drugs that
judgment, provided the Health Care Service to require prior coverage authorization and Self-
you for the purpose of preventing, evaluating, Administered Prescription Drugs that may be
diagnosing or treating an illness, injury, disease covered under this plan.
or its symptoms, and that the Health Care Note: The Medication Guide is subject to
Service was:
change at any time. Please refer to our website
1. in accordance with Generally Accepted at www.floridablue.com for the most current
Standards of Medical Practice; guide or you may call the customer service
2. clinically appropriate, in terms of type, phone number on your Identification Card for
frequency, extent, site and duration, and current information.
considered effective for your illness, injury or Mental Health Professional means a person
disease; and properly licensed to provide mental health
3. not primarily for your convenience, or that of Services, pursuant to Chapter 491 of the Florida
your Physician or other health care Provider, Statutes, or a similar applicable law of another
and not more costly than an alternative state. This professional may be a clinical social
DefirnUons 23-10
worker, mental health counselor or marriage and of-Network means,when used in reference to a
family therapist. A Mental Health Professional Provider,that,at the time Covered Services are
does not include members of any religious rendered,the Provider is not an In-Network
denomination who provide counseling services. Provider under the terms of this Booklet.
Mental and Nervous Disorder means any Out-of-Network Provider means a Provider
disorder listed in the diagnostic categories of the who, at the time Health Care Services were
International Classification of Diseases, Ninth rendered:
Edition, Clinical Modification(ICD-9 CM),or their 1. did not have a contract with us to participate
equivalents in the most recently published in NetworkBlue but was participating in our
version of the American Psychiatric Traditional Program; or
Association's Diagnostic and Statistical Manual 2, did not have a contract with a Host Blue to
of Mental Disorders, regardless of the underlying participate in its local PPO Program for
cause,or effect, of the disorder. purposes of the BlueCard(Out-of-State)
Midwife means a person properly licensed to PPO Program but was participating, for
practice midwifery pursuant to Chapter 467 of purposes of the BlueCard(Out-of-State)
the Florida Statutes, or a similar applicable law Program, as a BlueCard(Out-of-State)
of another state. Traditional Program Provider; or
NetworkBlue means,or refers to, the preferred 3. did have a contract to participate in
provider network established and so designated NetworkBlue but was not included in the
by BCBSF which is available to individuals panel of Providers designated by us to be
covered under this Benefit Booklet. Please note
In-Network for your Plan; or
that BCBSF's Preferred Patient Care(PPC) 4. did not have a contract with us to participate
preferred provider network is not available to in NetworkBlue or our Traditional Program;
individuals covered under this Benefit Booklet. or
5. did not have a contract with a Host Blue to
Occupational Therapist means a person participate for purposes of the BlueCard
properly licensed to practice Occupational (Out-of-State)Program as a BlueCard(Out-
Therapy pursuant to Chapter 468 of the Florida
� Statutes, or a similar applicable law of another of State)Traditional Program Provider.
state. Outpatient Rehabilitation Facility means an
entity which renders,through providers properly
Occupational Therapy means a treatment that licensed pursuant to Florida law or the similar
follows an illness or injury and is designed to law or laws of another state: outpatient physical
help a patient learn to use a newly restored or therapy; outpatient speech therapy;
previously impaired function. P P py; outpatient
occupational therapy; outpatient cardiac
Orthotic Device means any rigid or semi-rigid rehabilitation therapy; and outpatient Massage
device needed to support a weak or deformed for the primary purpose of restoring or improving
body part or restrict or eliminate body a bodily function impaired or eliminated by a
movement. Condition. Further, such an entity must meet
BCBSF's criteria for eligibility as an Outpatient
Out-of-Network means,when used in reference Rehabilitation Facility.The term Outpatient
to Covered Services,the level of benefits Rehabilitation Facility, as used herein, shall not
payable to an Out-of-Network Provider as include any Hospital including a general acute
designated on the Schedule of Benefits under care Hospital, or any separately organized unit
the heading"Out-of-Network". Otherwise,Out- of a Hospital,which provides comprehensive
DefirnUons 23-11
medical rehabilitation inpatient services, or Statutes,or a similar applicable law of another
rehabilitation outpatient services, including, but state.
not limited to,a Class III "specialty rehabilitation
hospital" described in Chapter 59A, Florida Physician Specialty Society means a United
Administrative Code or the similar law or laws of States medical specialty society that represents
another state. diplomates certified by a board recognized by
the American Board of Medical Specialties.
Pain Management includes, but is not limited Post-Service Claim means an
to, Services for pain assessment, medication, y paper or
electronic request or application for coverage,
physical therapy, biofeedback, and/or benefits, or a
counseling. Pain rehabilitation programs are payment for a Service actually
Provided to you(notjust proposed or
programs featuring multidisciplinary Services
recommended)that is received by us on a
directed toward helping those with chronic pain
to reduce or limit their pain. properly completed claim form or electronic
format acceptable to us in accordance with the
Partial Hospitalization means treatment in provisions of this section.
which an individual receives at least seven Pre-Service Claim means any request or
hours of institutional care during a portion of a application for coverage or benefits for a Service
24-hour period and returns home or leaves the
that has not yet been provided to you and with
treatment facility during any period in which respect to which the terms of the Benefit Booklet
treatment is not scheduled. A Hospital shall not condition payment for the Service(in whole or in
be considered a"home"for purposes of this
definition. part)on approval by us of coverage or benefits
for the Service before you receive it. A Pre-
Physical Therapy means the treatment of Service Claim may be a Claim Involving Urgent
disease or injury by physical or mechanical Care. As defined herein,a Pre-Service Claim
means as defined in Chapter 486 of the Florida shall not include a request for a decision or
Statutes or a similar applicable law of another opinion by us regarding coverage, benefits, or
state. Such therapy may include traction, active payment for a Service that has not actually been
or passive exercises, or heat therapy. rendered to you if the terms of the Benefit
Physical Therapist means a person properly Booklet do not require(or condition payment
licensed to practice Physical Thera upon)approval by us of coverage or benefits for
p y Therapy pursuant the Service before it is received.
to Chapter 486 of the Florida Statutes,or a
similar applicable law of another state. Prescription Drug means any medicinal
substance, remedy, vaccine, biological product,
Physician means any individual who is properly drug,pharmaceutical or chemical compound
licensed by the state of Florida, or a similar which can only be dispensed with a Prescription
applicable law of another state, as a Doctor of and/or which is required by state law to bear the
Medicine(M.D.), Doctor of Osteopathy(D.O.), following statement or similar statement on the
Doctor of Podiatry(D.P.M.), Doctor of label: "Caution: Federal law prohibits
Chiropractic(D.C.), Doctor of Dental Surgery or dispensing without a Prescription".
Dental Medicine(D.D.S. or D.M.D.), or Doctor of
Optometry(O.D.). Prior/Concurrent Coverage Affidavit means
the form that an Eligible Employee or Eligible
Physician Assistant means a person properly Dependent can submit to BCBSF as proof of the
licensed pursuant to Chapter 458 of the Florida amount of time the Eligible Employee was
covered under Creditable Coverage.
DefimOons 23_12
Prosthetist/Orthotist means a person or entity Rehabilitative Therapies means therapies the
that is properly licensed, if applicable, under primary purpose of which is to restore or
Florida law,or a similar applicable law of improve bodily or mental functions impaired or
another state,to provide services consisting of eliminated by a Condition, and include, but are
the design and fabrication of medical devices not limited to, Physical Therapy, Speech
such as braces, splints, and artificial limbs Therapy, Pain Management, pulmonary therapy
prescribed by a Physician. or Cardiac Therapy.
Prosthetic Device means a device which Self-Administered Prescription Drug means
replaces all or part of a body part or an internal an FDA-approved Prescription Drug that you
body organ or replaces all or part of the may administer to yourself, as recommended by
functions of a permanently inoperative or a Physician.
malfunctioning body part or organ.
Skilled Nursing Facility means an institution or
Provider means any facility, person or entity part thereof which meets BCBSF's criteria for
recognized for payment by BCBSF under this eligibility as a Skilled Nursing Facility and which:
Booklet. 1)is licensed as a Skilled Nursing Facility by the
state of Florida or a similar applicable law of
Psychiatric Facility means a facility properly another state; and 2)is accredited as a Skilled
licensed under Florida law, or a similar Nursing Facility by the Joint Commission on
applicable law of another state,to provide for the Accreditation of Healthcare Organizations or
care and treatment of Mental and Nervous recognized as a Skilled Nursing Facility by the
Disorders. For purposes of this Booklet, a Secretary of Health and Human Services of the
Psychiatric Facility is not a Hospital or a United States under Medicare, unless such
Substance Abuse Facility,as defined herein. accreditation or recognition requirement has
Psychologist means a person properly licensed been waived by BCBSF.
to practice psychology pursuant to Chapter 490 Sound Natural Teeth means teeth that are
of the Florida Statutes, or a similar applicable whole or properly restored(restoration with
law of another state. amalgams, resin or composite only); are without
Registered Nurse means a person properly impairment, periodontal, or other conditions; and
licensed to practice professional nursing are not in need of Services provided for any
pursuant to Chapter 464 of the Florida Statutes, reason other than an Accidental Dental Injury.
or a similar applicable law of another state. Teeth previously restored with a crown, inlay,
onlay, or porcelain restoration, or treated with
Registered Nurse First Assistant(RNFA) endodontics, are not Sound Natural Teeth.
means a person properly licensed to perform
surgical first assisting services pursuant to Specialty Drug means an FDA-approved
Chapter 464 of the Florida Statutes or a similar Prescription Drug that has been designated,
applicable law of another state. solely by us, as a Specialty Drug due to special
handling, storage,training, distribution
Rehabilitation Services means Services for the requirements and/or management of therapy.
purpose of restoring function lost due to illness, Specialty Drugs may be Provider administered
injury or surgical procedures including but not or self-administered and are identified with a
limited to cardiac rehabilitation, pulmonary special symbol in the Medication Guide.
rehabilitation, Occupational Therapy, Speech
Therapy, Physical Therapy and Massage Specialty Pharmacy means a Pharmacy that
Therapy. has signed a Participating Pharmacy Provider
Definitions 23-13
Agreement with us to provide specific organizations as designated under the Blue
Prescription Drug products, as determined by Cross and Blue Shield Association's BlueCard
us. In-Network Specialty Pharmacies are listed Program.
in the Medication Guide.
Traditional Program Providers means,or
Speech Therapy means the treatment of refers to,those health care Providers who are
speech and language disorders by a Speech not NetworkBlue Providers, but who, or which, at
Therapist including language assessment and the time you received Services from them were
language restorative therapy services. participating in the Traditional Program. For
Stabilize shall have the same meaning with purposes of payment under this Benefit Booklet
only,the term Traditional Program Provider also
regard to Emergency Services as the term is refers,when applicable, to any health care
defined in Section 1867 of the Social Security Provider located outside the state of Florida who
Act. or which, at the time Health Care Services were
Speech Therapist means a person properly rendered to you, participated as a BlueCard
licensed to practice Speech Therapy pursuant to Traditional Provider under the Blue Cross and
Chapter 468 of the Florida Statutes, or a similar Blue Shield Association's BlueCard Program.
applicable law of another state. Traditional providers are considered out of
network for benefit calculation purposes;
Standard Reference Compendium means: however, does not balance bill the member.
1)the United States Pharmacopoeia Drug
Information; 2)the American Medical
Association Drug Evaluation;or 3)the American
Urgent Care Center means a facility properly
Hospital Formulary Service Hospital Drug licensed that: 1)is available to provide Services
Information.
to patients at least 60 hours per week with at
Substance Abuse Facility means a facility least twenty-five(25)of those available hours
properly licensed under Florida law, or a similar after 5:00 p.m. on weekdays or on Saturday or
applicable law of another state,to provide Sunday;2)posts instructions for individuals
necessary care and treatment for Substance seeking Health Care Services, in a conspicuous
Dependency. For the purposes of this Booklet a public place, as to where to obtain such
Substance Abuse Facility is not a Hospital or a Services when the Urgent Care Center is
Psychiatric Facility, as defined herein. closed; 3)employs or contracts with at least one
or more Board Certified or Board Eligible
Substance Dependency means a Condition Physicians and Registered Nurses(RNs)who
where a person's alcohol or drug use injures his are physically present during all hours of
or her health; interferes with his or her social or operation. Physicians, RNs, and other medical
economic functioning; or causes the individual to professional staff must have appropriate training
lose self-control. and skills for the care of adults and children; and
Traditional Program means, or refers to, 4)maintains and operates basic diagnostic
BCBSF's provider contracting programs called radiology and laboratory equipment in
Payment for Physician Services(PPS)and compliance with applicable state and/or federal
Payment for Hospital Services(PHS). For laws and regulations.
purposes of this Benefit Booklet, the term For purposes of this Benefit Booklet, an Urgent
Traditional Program also refers,when Care Center is not a Hospital, Psychiatric
applicable,to the traditional Provider contracting Facility, Substance Abuse Facility, Skilled
programs of other Blue Cross and/or Blue Shield
I
Definitions 23-14
Nursing Facility or Outpatient Rehabilitation
Facility.
Waiting Period means the length of time
established by Monroe County BOCC which
must be met by an individual before that
individual becomes eligible for coverage under
this Benefit Booklet.
Zygote Intrafallopian Transfer(ZIFT)means a
process in which an egg is fertilized in the
laboratory and the resulting zygote is transferred
to the fallopian tube at the pronuclear stage
(before cell division takes place). The eggs are
retrieved and fertilized on one day and the
zygote is transferred the following day.
Definitions 23-15
Qualified Medical Child Support Orders Disclaimer
Qualified Medical Child Support Orders- The Plan will provide benefits as required byany
Qualified Medical Child Support Order (MCSO). A MCSO can be either:1) A Qualified Medical Child
Support Order (MCSO) that satisfies the requirements of Section 609(a) of ERISA;or 2)A National
Medical Support Notice(NMSN)that satisfies the requirements of Section 1908 of the Social Security Act.
Upon receipt of a MCSO or NMSN by a Covered Employee/Retiree notification must be given to the
Monroe County Group Health Plan Administrator(Benefits Office)within 31 days of receipt. The Covered
Employee/Retiree will need to provide any reasonable information or assistance to the Monroe County
Group Health Plan Administrator(Benefits Office)in connection with the MCSO.
Disclaimer 1
Current
BlueOptions
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
BlueOptions
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
A Self-funded Group Health
Benefit Plan
For Customer Service
Assistance: (800) 664-5295
B061 1—11/01111
Divisions 001,COI,R01,R02,002
Table of Contents
Section 1: How to Use Your Benefit Booklet............................................................. 1-1
Section 2: What Is Covered?.....................................................................................2-1
Section 3: What Is Not Covered?..............................................................................3-1
Section 4: Medical Necessity....................................................................................4-1
Section 5: Understanding Your Share of Health Care Expenses ..............................5-1
Section 6: Physicians, Hospitals and Other Provider Options...................................6-1
I
Section 7: BlueCard°(Out-of-State) Program...........................................................7-1
Section 8: Blueprint for Health Programs.................. .............8-1
Section 9: Pre-existing Conditions Exclusion Period.................................................9-1
Section 10: Eligibility for Coverage.............................
Section 11: Enrollment and Effective Date of Coverage............................................ 11-1
Section 12: Termination of Coverage........................................................................ 12-1
Section 13: Continuing Coverage Under COBRA
Section 14: Conversion Privilege...................................................................14-1
Section 15: Extension of Benefits..................................................................15-1
I
Section 16: The Effect of Medicare Coverage/ Medicare Secondary Payer
Provisions ..................... 16-1
Section 17: Duplication of Coverage Under Other Health Plans/Programs............... 17-1
Section18: Subrogation............................................................................................ 18-1
Section 19: Right of Reimbursement......................................................................... 19-1
Section 20: Claims Processing..................................................................................20-1
Section 21: Relationship Between the Parties...........................................................21-1
Section 22: General Provisions.................................................................................22-1
Section 23: Definitions...............................................................................................23-1
Table of Contents
Section 1 : How to Use Your Benefit Booklet
This is your Benefit Booklet("Booklet"). It be coordinated with other policies or plans;
describes your coverage, benefits, limitations and the Group Health Plan's subrogation
and exclusions for the self-funded Group Health rights and right of reimbursement.
Benefit Plan ("Group Health Plan" or"Group You will need to refer to the Schedule of
Plan")established and maintained by Monroe Benefits to determine how much you have to
County BOCC.
pay for particular Health Care Services.
The sponsor of your Group Health Plan has
contracted with Blue Cross Blue Shield of When reading your Booklet, please
Florida, Inc. (BCBSF), under an Administrative remember that:
Services Only Agreement("ASO Agreement"), . you should read this Booklet in its entirety in
to provide certain third party administrative
services, including claims processing, customer order to determine if a particular Health Care
Service is covered.
service, and other services, and access to
certain of its Provider networks. BCBSF • the headings of sections contained in this
provides certain administrative services only and Booklet are for reference purposes only and
does not assume any financial risk or obligation shall not affect in any way the meaning or
with respect to Health Care Services rendered to interpretation of particular provisions.
Covered Persons or claims submitted for • references to"you"or"your"throughout refer
processing under this Benefit Booklet for such to you as the Covered Plan Participant and to
Services.The payment of claims under the your Covered Dependents, unless expressly
Group Health Plan depends exclusively upon stated otherwise or unless, in the context in
the funding provided by Monroe County BOCC. which the term is used,it is clearly intended
You should read your Benefit Booklet carefully otherwise. Any references which refer solely
before you need Health Care Services. It to you as the Covered Plan Participant or
contains valuable information about: solely to your Covered Dependent(s)will be
• your BlueOptions benefits; noted as such.
• references to"we", "us",and"our"throughout
• what is covered; refer to Blue Cross and Blue Shield of
• what is excluded or not covered; Florida, Inc. We may also refer to ourselves
• coverage and payment rules; as"BCBSF".
• Blueprint for Health Programs;
• if a word or phrase starts with a capital letter,
�
it is either the first word in a sentence, a
• how and when to file a claim; proper name, a title, or a defined term. If the
• how much,and under what circumstances, word or phrase has a special meaning, it will
payment will be made; either be defined in the Definitions section or
defined within the particular section where it
• what you will have to pay as your share; and is used.
• other important information including when
benefits may change; how and when
coverage stops; how to continue coverage if
you are no longer eligible; how benefits will
How to Use Your Benefit Booklet _�
Where do you find information on........
• what particular types of Health Care • how to add or remove a Dependent?
Services are covered? Read the"Enrollment and Effective Date of
Read the"What Is Covered?"and"What Is Coverage"section.
Not Covered?" sections.
• what happens if you are covered under
• how much will be paid under your Group this Benefit Booklet and another health
Health Plan and how much do you have to plan?
pay? Read the"Duplication of Coverage Under
Read the"Understanding Your Share of Other Health Plans Programs"section.
Health Care Expenses" section along with the . what happens when your coverage ends?
Schedule of Benefits.
• how the amount you pay for Covered Read the"Termination of Coverage"section.
Services under the BlueCard® (Out-of- • what the terms used throughout this
State) Program will be determined when Booklet mean?
you receive care outside the state of Read the"Definitions" section.
Florida?
Read the"BlueCard®(Out-of-State)Program"
section.
Overview of How BlueOptions Works
Whenever you need care,you have a choice. If you visit an:
In-Network Provider Out-of-Network Provider
You receive In-Network benefits,the You receive the Out-of-Network level of
highest level of coverage available. benefits—you will share more of the cost of
your care.
You do not have to file a claim;the claim You may be required to submit a claim form.
will be filed by the In-Network Provider for
you.
The In-Network Provider*is responsible You should notify BCBSF of inpatient
for Admission Notification if you are admissions.
admitted to the Hospital.
*For Services rendered by an In-Network Provider located outside of Florida, you should
notify us of inpatient admissions.
How to Use Your Benefit Booklet 1.2
Section 2: What Is Covered?
Introduction Necessity coverage criteria then in effect,
except as specified in this section;
This section describes the Health Care Services
that are covered under this Benefit Booklet. All 4. in accordance with the benefit guidelines
benefits for Covered Services are subject to
listed below;
your share of the cost and the benefit 5. rendered while your coverage is in force;
maximums listed on your Schedule of Benefits, and
the applicable Allowed Amount, any limitations 6. not specifically or generally limited (e.g.,
and/or exclusions, as well as other provisions Pre-existing Condition exclusionary period)
contained in this Booklet, and any or excluded under this Booklet.
Endorsement(s)in accordance with BCBSF's
Medical Necessity coverage criteria and benefit BCBSF or Monroe County BOCC will determine
guidelines then in effect. whether Services are Covered Services under
this Booklet after you have obtained the
Remember that exclusions and limitations also Services and a claim has been received for the
apply to your coverage. Exclusions and Services. In some circumstances BCBSF or
limitations that are specific to a type of Service Monroe County BOCC may determine whether
are included along with the benefit description in Services might be Covered Services under this
this section. Additional exclusions and Booklet before you are provided the Service.
limitations that may apply can be found in the For example, BCBSF or Monroe County BOCC
"What Is Not Covered?"section. More than one may determine whether a proposed transplant is
limitation or exclusion may apply to a specific a Covered Service under this Booklet before the
Service or a particular situation. transplant is provided. Neither BCBSF nor
Expenses for the Health Care Services listed in Monroe County BOCC are obligated to
this section will be covered under this Booklet determine, in advance,whether any Service not
only if the Services are: yet provided to you would be a Covered Service
unless we have specifically designated that a
1. within the Health Care Services categories Service is subject to a prior authorization
in the"What Is Covered?" section; requirement as described in the "Blueprint for
2. actually rendered (not just proposed or Health Programs"section. We are also not
recommended)by an appropriately licensed obligated to cover or pay for any Service that
health care Provider who is recognized for has not actually been rendered to you.
payment under this Benefit Booklet and for In determining whether Health Care Services
which an itemized statement or description are Covered Services under this Booklet, no
of the procedure or Service which was written or verbal representation by any
rendered is received, including any employee or agent of BCBSF or Monroe County
applicable procedure code, diagnosis code BOCC, or by any other person, shall waive or
and other information required in order to otherwise modify the terms of this Booklet and,
process a claim for the Service; therefore, neither you, nor any health care
3. Medically Necessary, as defined in this Provider or other person should rely on any such
Booklet and determined by BCBSF in written or verbal representation.
accordance with BCBSF's Medical
What Is Covered
2-t
Our Benefit Guidelines number of tests performed by the Physician.
The Allowed Amount for allergy immunotherapy
In providing benefits for Covered Services,the treatment is based upon the type and number of
benefit guidelines listed below apply as well as doses.
any other applicable payment rules specific to
particular categories of Services: Ambulance Services
1. Payment for certain Health Care Services is Ambulance Services provided by a ground
included within the Allowed Amount for the vehicle may be covered provided it is necessary
primary procedure, and therefore no to transport you from:
additional amount is payable for any such 1. a Hospital which is unable to provide proper
Services. care to the nearest Hospital that can provide
2. Payment is based on the Allowed Amount proper care;
for the actual Service rendered(i.e., 2. a Hospital to your nearest home, or to a
payment is not based on the Allowed Skilled Nursing Facility;or
Amount for a Service which is more complex
than that actually rendered), and is not 3. the place a medical emergency occurs to
based on the method utilized to perform the the nearest Hospital that can provide proper
Service or the day of the week or the time of care.
day the procedure is performed. Expenses for Ambulance Services by boat,
3. Payment for a Service includes all airplane, or helicopter shall be limited to the
components of the Health Care Service Allowed Amount for a ground vehicle unless:
when the Service can be described by a 1. the pick-up point is inaccessible by ground
single procedure code, or when the Service vehicle;
is an essential or integral part of the
associated therapeutic/diagnostic Service 2. speed in excess of ground vehicle speed is
rendered. critical; or
3. the travel distance involved in getting you to
Covered Services Categories the nearest Hospital that can provide proper
care is too far for medical safety,as
Accident Care determined by BCBSF or Monroe County
Health Care Services to treat an injury or illness BOCC.
resulting from an Accident not related to your job Please refer to your Schedule of Benefits for the
or employment are covered. per-day maximums for ground transportation
Exclusion: and air/water transportation.
Health Care Services to treat an injury or illness Ambulatory Surgical Centers
resulting from an Accident related to your job or
employment are excluded. Health Care Services rendered at an Ambulatory
Surgical Center are covered and include:
Allergy Testing and Treatments 1. use of operating and recovery rooms;
Testing and desensitization therapy(e.g., 2. respiratory,or inhalation therapy(e.g.,
injections)and the cost of hyposensitization oxygen);
serum are covered. The Allowed Amount for
allergy testing is based upon the type and
What Is Covered? 2_2
3. drugs and medicines administered(except 1. well-baby and well-child screening for the
for take home drugs)at the Ambulatory presence of Autism Spectrum Disorder;
Surgical Center; 2. Applied Behavior Analysis,when rendered
4. intravenous solutions; by an individual certified pursuant to Section
5, dressings, including ordinary casts; 393.17 of the Florida Statutes or licensed
under Chapters 490 or 491 of the Florida
6. anesthetics and their administration; Statutes;and
7. administration of, including the cost of, 3. Physical Therapy by a Physical Therapist,
whole blood or blood products(except as Occupational Therapy by an Occupational
outlined in the Drugs exclusion of the"What
Therapist, and Speech Therapy by a
Is Not Covered?" section); Speech Therapist. Covered therapies
8. transfusion supplies and equipment; provided in the treatment of Autism
9. diagnostic Services, including radiology, Spectrum Disorder are covered even though
ultrasound, laboratory, pathology and they may be habilitative in nature(provided
approved machine testing(e.g., EKG); and to teach a function)and are not necessarily
limited to restoration of a function or skill that
10. chemotherapy treatment for proven has been lost.
malignant disease. Payment Guidelines for Autism Spectrum
Anesthesia Administration Services Disorder
Administration of anesthesia by a Physician or Autism Spectrum Disorder Services must be
Certified Registered Nurse Anesthetist("CRNA") authorized in accordance with BCBSF's
may be covered. In those instances where the
established criteria, before such Services are
rendered. Services performed without
CRNA is actively directed by a Physician other authorization will be denied. Authorization for
than the Physician who performed the surgical coverage is not required when Covered Services
procedure, payment for Covered Services,if are provided for the treatment of an Emergency
any,will be made for both the CRNA and the Medical Condition.
Physician Health Care Services at the lower
directed-services Allowed Amount in accordance Note: In order to determine whether such
with BCBSF's payment program then in effect Services are covered under this Benefit Booklet,
for such Covered Services. we reserve the right to request a formal written
treatment plan signed by the treating Physician
Exclusion: to include the diagnosis, the proposed treatment
Coverage does not include anesthesia Services type,the frequency and duration of treatment,
by an operating Physician, his or her partner or the anticipated outcomes stated as goals, and
associate. the frequency with which the treatment plan will
be updated, but no less than every 6 months.
Autism Spectrum Disorder This Benefit Booklet will only cover services to
the extent included in the treating physician's
Autism Spectrum Disorder Services provided to formal written treatment plan.
a Covered Dependent who is under the age of Breast Reconstructive Surgery
18,or if 18 years of age or older, is attending
high school and was diagnosed with Autism Surgery to reestablish symmetry between two
Spectrum Disorder prior to his or her 9"birthday breasts and implanted prostheses incident to
consisting of: Mastectomy is covered. In order to be covered,
such surgery must be provided in a manner
What is Covered? y 3
chosen by your Physician, consistent with 2. Extraction of teeth required prior to radiation
prevailing medical standards,and in consultation therapy when you have a diagnosis of
with you. cancer of the head and/or neck.
Child Cleft Lip and Cleft Palate Treatment 3. Anesthesia Services for dental care
including general anesthesia and
Treatment and Services for Child Cleft Lip and hospitalization Services necessary to assure
Cleft Palate, including medical, dental, Speech the safe delivery of necessary dental care
Therapy,audiology, and nutrition Services for
provided to you or your Covered Dependent
treatment of a child under the age of 18 who has in a Hospital or Ambulatory Surgical Center
cleft lip or cleft palate are covered. In order for if:
such Services to be covered, your Covered
Dependent's Physician must specifically a) the Covered Dependent is under 8
prescribe such Services and such Services must years of age and it is determined by a
be medically necessary and consequent to dentist and the Covered Dependent's
treatment of the cleft lip or cleft palate. Physician that:
Concurrent Physician Care
i. dental treatment is necessary due to
a dental Condition that is
Concurrent Physician care Services are significantly complex; or
covered, provided: (a)the additional Physician
actively participates in your treatment;(b)the ii. the Covered Dependent has a
Condition involves more than one body system developmental disability in which
or is so severe or complex that one Physician patient management in the dental
cannot provide the care unassisted;and(c)the office has proven to be ineffective;
Physicians have different specialties or have the or
same specialty with different sub-specialties. b) you or your Covered Dependent have j
Consultations
one or more medical Conditions that
would create significant or undue
Consultations provided by a Physician are medical risk for you in the course of
covered if your attending Physician requests the delivery of any necessary dental
consultation and the consulting Physician treatment or surgery if not rendered in a
prepares a written report. Hospital or Ambulatory Surgical Center.
Contraceptive Injections Exclusion:
Medication by injection is covered when 1. Dental Services provided more than 90
provided and administered by a Physician,for days after the date of an Accidental
the purpose of contraception, and is limited to Dental Injury regardless of whether or
the medication and administration when not such services could have been
medically necessary. rendered within 90 days; and
Dental Services 2. Dental Implant.
Dental Services are limited to the following: Diabetes Outpatient Self-Management
1. Care and stabilization treatment rendered
within 90 days of an Accidental Dental Injury Diabetes outpatient self-management training
to Sound Natural Teeth. and educational Services and nutrition
counseling (including all Medically Necessary
equipment and supplies)to treat diabetes, if
What Is Covered? 2-0
your treating Physician or a Physician who Durable Medical Equipment
specializes in the treatment of diabetes certifies Durable Medical Equipment when provided by a
that such Services are Medically Necessary, are Durable Medical Equipment Provider and when
covered. In order to be covered,diabetes prescribed by a Physician, limited to the most
outpatient self-management training and cost-effective equipment as determined by
educational Services must be provided under BCBSF or Monroe County BOCC is covered.
the direct supervision of a certified Diabetes
Educator or a board-certified Physician Payment Guidelines for Durable Medical
specializing in endocrinology. Additionally, in Equipment
order to be covered, nutrition counseling must Supplies and service to repair medical
be provided by a licensed Dietitian. Covered equipment may be Covered Services only if you
Services may also include the trimming of own the equipment or you are purchasing the
toenails, corns,calluses, and therapeutic shoes equipment. Payment for Durable Medical
(including inserts and/or modifications)for the Equipment will be based on the lowest of the
treatment of severe diabetic foot disease. following: 1 g )the purchase
se price; 2)the
Diagnostic Services lease/purchase price; 3)the rental rate; or 4)the
Allowed Amount. The Allowed Amount for such
Diagnostic Services when ordered by a Physician are limited to the following: rental equipment will not exceed the total
y g purchase price. Durable Medical Equipment
1, radiology, ultrasound and nuclear medicine, includes, but is not limited to,the following:
Magnetic Resonance Imaging(MRI); wheelchairs,crutches, canes,walkers, hospital
2. laboratory and pathology Services; beds,and oxygen equipment.
3. Services involving bones or joints of the jaw Note: Repair or replacement of Durable
(e.g., Services to treat temporomandibular Medical Equipment due to growth of a child or
joint[TMJ]dysfunction)or facial region if, significant change in functional status is a
under accepted medical standards, such Covered Service.
diagnostic Services are necessary to treat Exclusion:
Conditions caused by congenital or Equipment which is primarily for convenience
developmental deformity, disease,or injury; and/or comfort; modifications to motor vehicles
4. approved machine testing (e.g., and/or homes,including but not limited to,
electrocardiogram [EKG], wheelchair lifts or ramps;water therapy devices
electroencephalograph (EEG], and other such as Jacuzzis, hot tubs, swimming pools or
electronic diagnostic medical procedures); whirlpools;exercise and massage equipment,
and electric scooters, hearing aids, air conditioners
5. genetic testing for the purposes of and purifiers, humidifiers,water softeners and/or
explaining current signs and symptoms of a purifiers, pillows, mattresses or waterbeds,
possible hereditary disease. escalators, elevators, stair glides, emergency
alert equipment, handrails and grab bars, heat
Dialysis Services appliances, dehumidifiers, and the replacement
Dialysis Services including equipment,training, of Durable Medical Equipment solely because it
and medical supplies, when provided at any is old or used are excluded.
location by a Provider licensed to perform
dialysis including a Dialysis Center are covered. Emergency Services
What Is Covered
2-5
Emergency Services for an Emergency Medical (e.g., radial keratotomy, PRK and LASIK)are
Condition are covered when rendered In- excluded.
Network and Out-of-Network without the need
for any prior authorization determination by us. Home Health Care
When Emergency Services and care for an The Home Health Care Services listed below
Emergency Medical Condition are rendered by are covered when the following criteria are met:
an Out-of-Network Provider, any Copayment 1. you are unable to leave your home without
and/or Coinsurance amount applicable to In- considerable effort and the assistance of
Network Providers for Emergency Services will another person because you are: bedridden
also apply to such Out-of-Network Provider. or chairbound or because you are restricted
Enteral Formulas
in ambulation whether or not you use
assistive devices;or you are significantly
Prescription and non-prescription enteral limited in physical activities due to a
formulas for home use when prescribed by a Condition; and
Physician as necessary to treat inherited
2. the Home Health Care Services rendered
diseases of amino acid, organic acid,
carbohydrate or fat metabolism as well as have been prescribed by a Physician by way
malabsorption originating from congenital of a formal written treatment plan that has
defects present at birth or acquired during the been reviewed and renewed by the
neonatal period are covered. prescribing Physician every 30 days. In
order to determine whether such Services
Coverage to treat inherited diseases of amino are covered under this Booklet, you may be
acid and organic acids,for you up to your 25th
birthday, shall include coverage for food required to provide a copy of any written
products modified to be low protein. treatment plan;
3. the Home Health Care Services are
Eye Care provided directly by(or indirectly through)a
Coverage includes the following Services: Home Health Agency; and
1. Physician Services, soft lenses or sclera 4. you are meeting or achieving the desired
shells,for the treatment of aphakic patients; treatment goals set forth in the treatment
2. initial glasses or contact lenses following plan as documented in the clinical progressnotes.
cataract surgery; and
3. Physician Services to treat an injury to or Home Health Care Services are limited to:
disease of the eyes. 1. part-time(i.e., less than 8 hours per day and
Exclusion: less than a total of 40 hours in a calendar
week)or intermittent(i.e., a visit of up to, but
Health Care Services to diagnose or treat vision not exceeding, 2 hours per day) nursing
problems which are not a direct consequence of care by a Registered Nurse, Licensed
trauma or prior ophthalmic surgery;eye Practical Nurse and/or home health aide
examinations; eye exercises or visual training; Services;
eye glasses and contact lenses and their fitting
are excluded. In addition to the above, any 2• home health aide Services must be
surgical procedure performed primarily to correct consistent with the plan of treatment,
or improve myopia or other refractive disorders
What Is Covered? 2-6
ordered by a Physician, and rendered under 1. room and board in a semi-private room
the supervision of a Registered Nurse; when confined as an inpatient, unless the
patient must be isolated from others for
3. medical social services; documented clinical reasons;
4. nutritional guidance; 2. intensive care units, including cardiac,
5. respiratory,or inhalation therapy(e.g., progressive and neonatal care;
oxygen); and 3. use of operating and recovery rooms;
6. Physical Therapy by a Physical Therapist, 4. use of emergency rooms;
Occupational Therapy by a Occupational
Therapist, and Speech Therapy by a 5. respiratory, pulmonary, or inhalation therapy
Speech Therapist. (e.g.,oxygen);
Exclusions: 6. drugs and medicines administered(except
for take home drugs) by the Hospital;
1. homemaker or domestic maid services;
7. intravenous solutions;
2. sitter or companion services;
8. administration of, including the cost of,
3. Services rendered by an employee or whole blood or blood products(except as
operator of an adult congregate living outlined in the Drugs exclusion of the"What
facility; an adult foster home;an adult day Is Not Covered?"section);
care center,or a nursing home facility;
9. dressings, including ordinary casts;
4. Speech Therapy provided for a diagnosis of
developmental delay; 10. anesthetics and their administration;
5. Custodial Care except for any such care 11. transfusion supplies and equipment;
covered under this subsection when 12. diagnostic Services, including radiology,
provided on a part-time or intermittent basis ultrasound, laboratory, pathology and
(as defined above)by a home health aide; approved machine testing (e.g., EKG);
6. food, housing, and home delivered meals; 13. Physical, Speech, Occupational, and
and Cardiac Therapies; and
7. Services rendered in a Hospital, nursing 14. transplants as described in the Transplant
home, or intermediate care facility. Services subsection.
Hospice Services Exclusion:
Health Care Services provided in connection Expenses for the following Hospital Services are
with a Hospice treatment program may be excluded when such Services could have been
Covered Services, provided the Hospice provided without admitting you to the Hospital:
treatment program is: 1)room and board provided during the
admission; 2) Physician visits provided while you
1. approved by your Physician;and were an inpatient;3)Occupational Therapy,
2. your doctor has certified to us in writing that Speech Therapy, Physical Therapy, and Cardiac
your life expectancy is 12 months or less. Therapy; and 4)other Services provided while
Recertification is required every six months. you were an inpatient.
In addition, expenses for the following and
Hospital Services similar items are also excluded:
Covered Hospital Services include: 1. gowns and slippers;
What Is Covered? 2-7
2. shampoo,toothpaste, body lotions and respiratory ventilator management Services are
hygiene packets; excluded.
3. take-home drugs;
Mammograms
4, telephone and television;
Mammograms obtained in a medical office,
5. guest meals or gourmet menus;and medical treatment facility or through a health
6. admission kits. testing service that uses radiological equipment
registered with the appropriate Florida regulatory
Inpatient Rehabilitation agencies(or those of another state)for
diagnostic purposes or breast cancer screening
Inpatient Rehabilitation Services are covered are Covered Services.
when the following criteria are met:
Benefits for mammograms may not be subject to
1. Services must be provided under the the Deductible,Coinsurance, or Copayment(if
direction of a Physician and must be applicable). Please refer to your Schedule of
provided by a Medicare certified facility in Benefits for more information.
accordance with a comprehensive
rehabilitation program; Mastectomy Services
2. a plan of care must be developed and Breast cancer treatment including treatment for
managed by a coordinated multi-disciplinary
team; physical complications relating to a Mastectomy
(including lymphedemas), and outpatient post-
3. coverage is limited to the specific acute, surgical follow-up in accordance with prevailing
catastrophic target diagnoses of severe medical standards as determined by you and
stroke, multiple trauma, brain/spinal injury, your attending Physician are covered.
severe neurological motor disorders,and/or Outpatient post-surgical follow-up care for
severe burns; Mastectomy Services shall be covered when
4. the individual must be able to actively provided by a Provider in accordance with the
prevailing medical standards and at the most
participate in at least 2 rehabilitative medically appropriate setting. The setting may
therapies and be able to tolerate at least 3 hours per day of skilled Rehabilitation be the Hospital, Physician's office, outpatient Services for at least 5 days a week and their center, or your home. The treating Physician,after consultation with you, may choose the
Condition must be likely to result in
significant improvement; and appropriate setting.
5. the Rehabilitation Services must be required Maternity Services
at such intensity,frequency and duration as Health Care Services,including prenatal care,
to make it impractical for the individual to delivery and postpartum care and assessment,
receive services in a less intensive setting. provided to you, by a Doctor of Medicine(M.D.),
Inpatient Rehabilitation Services are subject to Doctor of Osteopathy(D.O.), Hospital, Birth
the inpatient facility Copayment, if applicable, Center, Midwife or Certified Nurse Midwife may
and the benefit maximum set forth in the be Covered Services. Care for the mother
Schedule of Benefits. includes the postpartum assessment.
Exclusion: In order for the postpartum assessment to be
covered, such assessment must be provided at
All Substance Dependency, drug and alcohol a Hospital, an attending Physician's office, an
related diagnoses, Pain Management, and
What Is Covered
2-8
outpatient maternity center, or in the home by a include the administration of the Prescription
qualified licensed health care professional Drug.
trained in care for a mother. Coverage under
this Booklet for the postpartum assessment Your plan may also include a maximum monthly
includes coverage for the physical assessment amount you will be required to pay out-of-pocket
of the mother and any necessary clinical tests in for Medical Pharmacy,when such Services are
keeping with prevailing medical standards. provided by an In-Network Provider or Specialty
Pharmacy. If your plan includes a Medical
Under Federal law, your Group Plan generally Pharmacy out-of-pocket monthly maximum, it
may not restrict benefits for any hospital length will be listed on your Schedule of Benefits and
of stay in connection with childbirth for the only applies after you have met your Deductible,
mother or newborn child to less than 48 hours if applicable.
following a vaginal delivery; or less than 96
hours following a cesarean section. However, Please refer to your Schedule of Benefits for the
Federal law generally does not prohibit the additional Cost Share amount and/or monthly
mother's or newborn's attending Provider, after maximum out-of-pocket applicable to Medical
consulting with the mother, from discharging the Pharmacy for your plan.
mother or her newborn earlier than 48 hours(or Note: For purposes of this benefit,allergy
96 as applicable). In any case, under Federal injections and immunizations are not considered
law,your Group Plan can only require that a Medical Pharmacy.
provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours(or Mental Health Services
96 hours).
Diagnostic evaluation, psychiatric treatment,
Exclusion: individual thera
py, and group therapy provided
Maternity Services rendered to a Covered to you by a Physician, Psychologist, or Mental
Person who becomes pregnant as a Gestational Health Professional for the treatment of a Mental
Surrogate under the terms of, and in accordance and Nervous Disorder may be covered. These
with, a Gestational Surrogacy Contract or Health Care Services include inpatient,
Arrangement are excluded. This exclusion outpatient, and Partial Hospitalization services.
applies to all expenses for prenatal, intra-partal, Partial Hospitalization is a Covered Service
and post-partal Maternity/Obstetrical Care, and when provided under the direction of a Physician
Health Care Services rendered to the Covered and in lieu of inpatient hospitalization.
Person acting as a Gestational Surrogate.
Exclusion:
For the definition of Gestational Surrogate and
Gestational Surrogacy Contract, see the 1. Services rendered in connection with a
"Definitions" section of this Benefit Booklet. Condition not classified in the diagnostic
categories of the International Classification
Medical Pharmacy of Diseases, Ninth Edition, Clinical
Modification (ICD-9 CM)or their equivalents
Physician-administered Prescription Drugs in the most recently published version of the
which are rendered in a Physician's office are American Psychiatric Association's
subject to a separate Cost Share amount that is Diagnostic and Statistical Manual of Mental
in addition to the office visit Cost Share amount. Disorders, regardless of the underlying
The Medical Pharmacy Cost Share amount cause,or effect, of the disorder;
applies to the Prescription Drug and does not
What Is Covered
2-9
2. Services for psychological testing An assessment of the newborn child is covered
associated with the evaluation and diagnosis provided the Services were rendered at a
of learning disabilities or for mental Hospital,the attending Physician's office, a Birth
retardation; Center,or in the home by a Physician, Midwife
or Certified Nurse Midwife, and the performance
3. Services extended beyond the period of any necessary clinical tests and
necessary for evaluation and diagnosis of immunizations are within prevailing medical
learning disabilities or for mental retardation; standards. These Services are not subject to
4. Services for marriage counseling, when not the Deductible.
rendered in connection with a Condition Ambulance Services,when necessary to
classified in the diagnostic categories of the transport the newborn child to and from the
International Classification of Diseases, nearest appropriate facility which is staffed and
Ninth Edition,Clinical Modification(ICD-9-
CM)or their equivalents in the most recently equipped to treat the newborn child's Condition,
published version of the American as determined by BCBSF or Monroe County
Psychiatric Association's Diagnostic and BOCC and certified by the attending Physician
Statistical Manual of Mental Disorders; as Medically Necessary to protect the health and
5. Services for pre-marital counseling;
safety of the newborn child, are covered.
6. Services for court-ordered care or testing, or Under Federal law, your Group Plan generally
required as a condition of parole or may not restrict benefits for any hospital length
probation; of stay in connection with childbirth for the
mother or newborn child to less than 48 hours
7. Services for testing of aptitude, ability, following a vaginal delivery; or less than 96
intelligence or interest(except as covered hours following a cesarean section. However,
under the Autism Spectrum Disorder Federal law generally does not prohibit the
subsection);
mother's or newborn's attending Provider, after
8. Services for testing and evaluation for the consulting with the mother,from discharging the
purpose of maintaining employment; mother or her newborn earlier than 48 hours(or
9. Services for cognitive remediation; 96 as applicable). In any case, under Federal
10. inpatient confinements that are primarily law, your Group Plan can only require that a
intended as a change of environment; or provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours(or
11. inpatient(over night)mental health Services 96 hours).
received in a residential treatment facility.
Newborn Care Orthotic Devices
A newborn child will be covered from the Orthotic Devices including braces and trusses
moment of birth provided that the newborn child for the leg,arm,neck and back, and special
is eligible for coverage and properly enrolled. surgical corsets are covered when prescribed by
Covered Services shall consist of coverage for a Physician and designed and fitted by an
injury or sickness,including the necessary care Orthotist.
or treatment of medically diagnosed congenital Benefits may be provided for necessary
defects, birth abnormalities, and premature birth. replacement of an Orthotic Device which is
Newborn Assessment: owned by you when due to irreparable damage,
wear, a change in your Condition, or when
necessitated due to growth of a child.
What Is Covered
2 10
Payment for splints for the treatment of 2. individuals who have vertebral
temporomandibular joint("TMJ")dysfunction is abnormalities;
limited to payment for one splint in a six-month 3. individuals who are receiving long-term
period unless a more frequent replacement is glucocorticoid (steroid)therapy;
determined by BCBSF or Monroe County BOCC
to be Medically Necessary. 4. individuals who have primary
hyperparathyroidism; and
Exclusion:
5. individuals who have a family history of
osteoporosis.
1. Expenses for arch supports,shoe inserts
designed to effect conformational changes Outpatient Cardiac,Occupational, Physical,
in the foot or foot alignment, orthopedic Speech, Massage Therapies and Spinal
shoes, over-the-counter, custom-made or Manipulation Services
built-up shoes, cast shoes, sneakers, ready- Outpatient therapies listed below may be
made compression hose or support hose, or Covered Services when ordered by a Physician
similar type devices/appliances regardless or other health care professional licensed to
of intended use,except for therapeutic perform such Services. The outpatient therapies
shoes(including inserts and/or listed in this category are in addition to the
modifications)for the treatment of severe Cardiac, Occupational, Physical and Speech
diabetic foot disease; Therapy benefits listed in the Home Health
2. Expenses for orthotic appliances or devices Care, Hospital, and Skilled Nursing Facility
categories herein.
which straighten or re-shape the
conformation of the head or bones of the Cardiac Therapy Services provided under the
skull or cranium through cranial banding or supervision of a Physician, or an appropriate
molding(e.g.dynamic orthotic cranioplasty Provider trained for Cardiac Therapy,for the
or molding helmets), except when the purpose of aiding in the restoration of normal
orthotic appliance or device is used as an heart function in connection with a myocardial
alternative to an internal fixation device as a infarction, coronary occlusion or coronary
result of surgery for craniosynostosis;and bypass surgery are covered.
3. Expenses for devices necessary to exercise, Occupational Therapy Services provided by a
train, or participate in sports, e.g. custom-
Physician or Occupational Therapist for the
made knee braces.
purpose of aiding in the restoration of a
previously impaired function lost due to a
Osteoporosis Screening, Diagnosis, and Condition are covered.
Treatment Speech Therapy Services of a Physician,
Screening, diagnosis,and treatment of Speech Therapist, or licensed audiologist to aid
osteoporosis for high-risk individuals is covered
in the restoration of speech loss or an
as medically necessary, including, but not impairment of speech resulting from a Condition
limited to: are covered.
Physical Therapy Services provided by a
1. estrogen-deficient individuals who are at physician or Physical Therapist for the purpose
clinical risk for osteoporosis; of aiding in the restoration of normal physical
function lost due to a Condition are covered.
What Is Covered? 2.11
Massage Therapy Massage provided by a maximum benefit listed in the Schedule of
Physician, Massage Therapist, or Physical Benefits,whichever occurs first.
Therapist when the Massage is prescribed as 2. Payment for covered Physical Therapy
being Medically Necessary by a Physician Services rendered on the same day as
licensed pursuant to Florida Statutes Chapter spinal manipulation is limited to one(1)
458(Medical Practice), Chapter 459 Physical Therapy treatment per day, not to
(Osteopathy), Chapter 460(Chiropractic)or
ChaChapter 461 (Podiatry) exceed fifteen(15)minutes in length.
p ( ry) is covered. The
Physician's prescription must specify the Your Schedule of Benefits sets forth the
number of treatments. maximum number of visits covered under this
Payment Guidelines for Massage and
plan for any combination of the outpatient
Physical Therapy therapies and spinal manipulation Services
listed above. For example, even if you may
1. Payment for covered Massage Services is have only been administered two(2)of the
limited to no more than four(4) 15-minute spinal manipulations for the Benefit Period, any
Massage treatments per day, not to exceed additional spinal manipulations for that Benefit
the Outpatient Cardiac, Occupational, Period will not be covered if you have already
Physical, Speech, and Massage Therapies met the combined therapy visit maximum with
and Spinal Manipulations benefit maximum other Services.
listed on the Schedule of Benefits.
2. Payment for a combination of covered Oxygen
Massage and Physical Therapy Services Expenses for oxygen,the equipment necessary
rendered on the same day is limited to no to administer it,and the administration of oxygen
more than four(4) 15-minute treatments per are covered.
day for combined Massage and Physical
Therapy treatment, not to exceed the Physician Services
Outpatient Cardiac, Occupational, Physical, Medical or surgical Health Care Services
Speech, and Massage Therapies and Spinal provided by a Physician, including Services
Manipulations benefit maximum listed on the rendered in the Physician's office, in an
Schedule of Benefits. outpatient facility, or electronically through a
3. Payment for covered Physical Therapy computer via the Internet.
Services rendered on the same day as
spinal manipulation is limited to one(1) Payment Guidelines for Physician Services
Physical Therapy treatment per day not to Provided by Electronic Means through a
exceed fifteen (15)minutes in length. Computer:
Spinal Manipulations: Services by Physicians Expenses for online medical Services provided
for manipulations of the spine to correct a slight electronically through a computer by a Physician
dislocation of a bone or joint that is via the Internet will be covered only if such
demonstrated by x-ray are covered. Services:
Payment Guidelines for Spinal Manipulation 1. were provided to a covered individual who
was, at the time the Services were provided,
1. Payment for covered spinal manipulation is an established patient of the Physician
limited to no more than 26 spinal rendering the Services;
manipulations per Benefit Period,or the
What Is Covered? 2-12
2. were in response to an online inquiry Committee on Immunization Practices of the
received through the Internet from the Centers for Disease Control and Prevention
covered individual with respect to which the established under the Public Health Service
Services were provided; and Act with respect to the individual involved;
3. were provided by a Physician through a and
secure online healthcare communication 3. with respect to women,such additional
services vendor that, at the time the preventive care and screenings not
Services were rendered,was under contract described in paragraph (1) as provided for in
with BCBSF. comprehensive guidelines supported
p g by the
The term "established patient,"as used herein, Health Resources and Services
shall mean that the covered individual has Administration.
received professional services from the Exclusion:
Physician who provided the online medical
Services, or another physician of the same Routine vision and hearing examinations and
specialty who belongs to the same group screenings are not covered, except as required
practice as that Physician, within the past three under paragraph number one above.
years.
Preventive Child Health Supervision Services
Exclusion:
Preventive Child Health Supervision Services
Expenses for online medical Services provided from the moment of birth up to the 17th birthday
electronically through a computer by a Physician are covered.
via the Internet other than through a healthcare
communication services vendor that has entered In order to be covered, Services shall be
into contract with BCBSF are excluded. provided in accordance with prevailing medical
Expenses for online medical Services provided standards consistent with:
by a health care provider that is not a Physician 1. evidence-based items or Services that have
and expenses for Health Care Services in effect a rating of'A'or'B' in the current
rendered by telephone are also excluded. recommendations of the U.S. Preventive
Services Task Force established under the
Preventive Adult Wellness Services Public Health Service Act;
Preventive adult wellness Services are covered 2. immunizations that have in effect a
under your plan. For purposes of this benefit, an recommendation from the Advisory
adult is 17 years or older. Committee on Immunization Practices of the
In order to be covered, Services shall be Centers for Disease Control and Prevention
provided in accordance with prevailing medical established under the Public Health Service
standards consistent with: Act with respect to the individual involved;
and
1. evidence-based items or Services that have
in effect a rating of'A'or`B' in the current
3. with respect to infants, children, and
recommendations of the U.S. Preventive adolescents,evidence-informed preventive
Services Task Force established under the care and screenings provided for in the
Public Health Service Act; comprehensive guidelines supported by the
Health Resources and Services
2. immunizations that have in effect a Administration.
recommendation from the Advisory Prosthetic Devices
What Is Covered? 2-13
The following Prosthetic Devices are covered Specialty Pharmacy or an Out-of-Network
when prescribed by a Physician and designed Provider that provides Specialty Drugs.
and fitted by a Prosthetist:
3. Specialty Drugs used to increase height or
1. artificial hands,arms,feet, legs and eyes, bone growth(e.g., growth hormone), must '
including permanent implanted lenses meet the following criteria in order to be
following cataract surgery, cardiac pacemakers, and prosthetic devices incident covered:
to a Mastectomy; a. Must be prescribed for Conditions of
2. appliances needed to effectively use artificial growth hormone deficiency documented
limbs or corrective braces; or with two abnormally low stimulation
tests of less than 10 ng/ml and one
3. penile prosthesis. abnormally low growth hormone
Covered Prosthetic Devices(except cardiac dependent peptide or for Conditions of
pacemakers, and Prosthetic Devices incident to growth hormone deficiency associated
Mastectomy)are limited to the first such with loss of pituitary function due to
permanent prosthesis(including the first trauma, surgery, tumors, radiation or
temporary prosthesis if it is determined to be disease, or for state mandated use as in
necessary)prescribed for each specific
patients with AIDS.
Condition.
b. Continuation of growth hormone therapy
Benefits may be provided for necessary is only covered for Conditions
replacement of a Prosthetic Device which is associated with significant growth
owned by you when due to irreparable damage, hormone deficiency when there is
wear,or a change in your Condition, or when evidence of continued responsiveness
necessitated due to growth of a child. to treatment. Treatment is considered
i
Exclusion: responsive in children less than 21
1. Expenses for microprocessor controlled or years of age,when the growth hormone
myoelectric artificial limbs(e.g. C-legs); and dependent peptide(IGF-1) is in the
normal range for age and Tanner
2. Expenses for cosmetic enhancements to development stage; the growth velocity
artificial limbs. is at least 2 cm per year, and studies
Self-Administered Prescription Drugs
demonstrate open epiphyses.
Treatment is considered responsive in
The following Self-Administered Drugs are both adolescents with closed epiphyses
covered: and for adults,who continue to evidence
1. Self-Administered Prescription Drugs used growth hormone deficiency and the IGF-
In the treatment of diabetes, cancer, 1 remains in the normal range for age
Conditions requiring immediate stabilization and gender.
(e g. anaphylaxis), or in the administration of Skilled Nursing Facilities
dialysis; and The following Health Care Services may be
2. Self-Administered Prescription Drugs Covered Services when you are an inpatient in a
identified as Specialty Drugs with a special Skilled Nursing Facility:
symbol in the Medication Guide when 1. room and board;
delivered to you at home and purchased at a
What Is Covered? 2_1 q
2, respiratory, pulmonary, or inhalation therapy 2. Physician, Psychologist and Mental Health
(e.g., oxygen); Professional outpatient visits for the care
3. drugs and medicines administered while an
and treatment of Substance Dependency.
inpatient(except take home drugs); Exclusion:
4. intravenous solutions; Expenses for prolonged care and treatment of
5. administration of, including the cost of,
Substance Dependency in a specialized
whole blood or blood products(except as inpatient or residential facility or inpatient
confinements that are primarily intended as a
' outlined in the Drugs exclusion of the "What change of environment are excluded.
Is Not Covered?"section);
6. dressings, including ordinary casts; Surgical Assistant Services
7. transfusion supplies and equipment; Services rendered by a Physician, Registered
Nurse First Assistant or Physician Assistant
8. diagnostic Services, including radiology,ultrasound, laboratory, atholo when acting as a surgical assistant(provided no
approved machine testing(e.g..,, EKG);and
' intern,resident, or other staff physician is
available)when the assistant is necessary are
9. chemotherapy treatment for proven covered.
malignant disease; and Surgical Procedures
10. Physical, Speech, and Occupational Surgical procedures performed by a Physician
Therapies; may be covered including the following:
A treatment plan from your Physician may be 1. sterilization(tubal ligations and
required in order to determine coverage and vasectomies), regardless of Medical
payment. Necessity;
Exclusion: 2. surgery to correct deformity which was
Expenses for an inpatient admission to a Skilled caused by disease, trauma, birth defects,
Nursing Facility for purposes of Custodial Care, growth defects or prior therapeutic
convalescent care, or any other Service processes;
primarily for the convenience of you and/or your 3. oral surgical procedures for excisions of
family members or the Provider are excluded. tumors,cysts,abscesses,and lesions of the
mouth;
Substance Dependency Care and Treatment
4. surgical procedures involving bones or joints
Care and treatment for Substance Dependency of the jaw(e.g., temporomandibutar joint
includes the following: [TMJ])and facial region if, under accepted
1. Health Care Services(inpatient and medical standards, such surgery is
outpatient or any combination thereof) necessary to treat Conditions caused by
provided by a Physician, Psychologist or congenital or developmental deformity,
Mental Health Professional in a program disease, or injury; and
accredited by the Joint Commission on the 5. Services of a Physician for the purpose of
Accreditation of Healthcare Organizations or rendering a second surgical opinion and
approved by the state of Florida(or another related diagnostic services to help determine
state)for Detoxification or Substance the need for surgery.
Dependency.
What Is Covered? 2-15
i
6. surgical procedures performed on a Covered primary procedure, and there is no
Plan Participant for the treatment of Morbid additional payment for any incidental
Obesity(e.g.,intestinal bypass, stomach procedure. An "incidental surgical
stapling, balloon dilation)and the associated procedure" includes surgery where one, or
care provided the Covered Plan Participant more than one,surgical procedure is
has not previously undergone the same or performed through the same incision or
similar procedure in the lifetime of this operative approach as the primary surgical
Group Health Plan when medically procedure which,in BCBSF's or Monroe
necessary. County BOCC's opinion, is not clearly
Exclusion: identified and/or does not add significant
time or complexity to the surgical session.
a. Surgical procedures for the treatment of For example,the removal of a normal
Morbid Obesity including:intestinal
appendix performed in conjunction with a
bypass; stomach stapling; balloon Medically Necessary hysterectomy is an
dilation and associated care for the incidental surgical procedure(i.e.,there is
surgical treatment of Morbid Obesity,if no payment for the removal of the normal
the Covered Plan Participant has appendix in the example).
previously undergone the same or
similar procedures in the lifetime of this 3. Payment for surgical procedures for fracture
Group Health Plan. Surgical procedures care,dislocation treatment, debridement,
performed to revise, or correct defects wound repair, unna boot, and other related
related to, a prior intestinal bypass, Health Care Services,is included in the
stomach stapling or balloon dilation are Allowed Amount of the surgical procedure.
also excluded.
Transplant Services
b. Reversal of a weight loss surgery,
surgical procedures to revise,correct, Transplant Services, limited to the procedures
and correction of defects to include listed below,may be covered when performed at
adjustment to devices implanted or any a facility acceptable to BCBSF or Monroe j
fills not performed during the initial County BOCC, subject to the conditions and
surgical event. limitations described below.
Payment Guidelines for Surgical Procedures Transplant includes pre-transplant, transplant
and post-discharge Services, and treatment of
1. Payment for multiple surgical procedures complications after transplantation. Benefits will
performed in addition to the primary surgical only be paid for Services, care and treatment
procedure,on the same or different areas of received or provided in connection with a:
the body, during the same operative session
will be based on 50 percent of the Allowed 1. Bone Marrow Transplant, as defined herein,
Amount for any secondary surgical which is specifically listed in the rule 59B-
procedure(s)performed. In addition, 12.001 of the Florida Administrative Code or
Coinsurance or Copayment(if any) indicated any successor or similar rule or covered by
in your Schedule of Benefits will apply. This Medicare as described in the most recently
guideline is applicable to all bilateral published Medicare Coverage Issues
procedures and all surgical procedures Manual issued by the Centers for Medicare
performed on the same date of service. and Medicaid Services. Coverage will be
provided for the expenses incurred for the
2. Payment for incidental surgical procedures donation of bone marrow by a donor to the
is limited to the Allowed Amount for the
What Is Covered) 2-16
same extent such expenses would be 2. transplant procedures involving the
covered for you and will be subject to the transplantation or implantation of any non-
same limitations and exclusions as would be human organ or tissue;
applicable to you. Coverage for the 3. transplant procedures related to the donation
reasonable expenses of searching for the or acquisition of an organ or tissue for a
donor will be limited to a search among recipient who is not covered under this
immediate family members and donors Benefit Booklet;
identified through the National Bone Marrow
Donor Program; 4. transplant procedures involving the implant of
an artificial organ,including the implant of the
2. corneal transplant; artificial organ;
3. heart transplant(including a ventricular 5. any organ,tissue, marrow, or stem cells
assist device, if indicated,when used as a which is/are sold rather than donated;
bridge to heart transplantation);
6. any Bone Marrow Transplant, as defined
4. heart-lung combination transplant; herein, which is not specifically listed in rule
5. liver transplant; 596-12.001 of the Florida Administrative
6. kidney transplant; Code or any successor or similar rule or
covered by Medicare pursuant to a national
7. pancreas; coverage decision made by the Centers for
8. pancreas transplant performed Medicare and Medicaid Services as
simultaneously with a kidney transplant; or evidenced in the most recently published
9. lung-whole single or whole bilateral Medicare Coverage Issues Manual;
transplant. 7. any Service in connection with the
identification of a donor from a local, state or
Coverage will be provided for donor costs and national listing, except in the case of a Bone
organ acquisition for transplants, other than Marrow Transplant;
Bone Marrow Transplants, provided such costs
are not covered in whole or in part by any other 8. any non-medical costs,including but not
insurance carrier, organization or person other limited to, temporary lodging or transportation
than the donor's family or estate. costs for you and/or your family to and from
You may call the customer service phone the approved facility; and
number indicated in this Booklet or on your 9. any artificial heart or mechanical device that
Identification Card in order to determine which replaces either the atrium and/or the
Bone Marrow Transplants are covered under ventricle.
this Booklet.
Exclusions:
Expenses for the following are excluded:
1. transplant procedures not included in the list
above, or otherwise excluded under this
Booklet(e.g., Experimental or Investigational
transplant procedures);
What Is Covered?
2-17
Section 3: What Is Not Covered?
Introduction modifications and purification therapies;
traditional Oriental medicine Including
Your Booklet expressly excludes expenses for acupuncture; naturopathic medicine;
the following Health Care Services, supplies, environmental medicine including the field of
drugs or charges. The following exclusions are clinical ecology;chelation therapy;
in addition to any exclusions specified in the thermography; mind-body interactions such as
"What is Covered?" section or any other section meditation, imagery, yoga, dance, and art
of the Booklet. therapy; biofeedback; prayer and mental
Abortions which are elective. healing; manual healing methods such as the
Alexander technique,aromatherapy, Ayurvedic
Adult Wellness preventive care or routine massage,craniosacral balancing, Feldenkrais
screening Services, except as specified under method, Hellerwork, polarity therapy, Reichian
the Preventive Adult Wellness Services category therapy, reflexology, rolfing, shiatsu, traditional
on the Schedule of Benefits. Chinese massage,Trager therapy, trigger-point
Arch Supports, shoe inserts designed to effect myotherapy, and biofield therapeutics; Reiki,
conformational changes in the foot or foot SHEN therapy, and therapeutic touch;
alignment, orthopedic shoes, over-the-counter,
bioelectromagnetic applications in medicine; and custom-made or built-up shoes, cast shoes, herbal therapies.
sneakers, ready-made compression hose or Complications of Non-Covered Services,
support hose, or similar type devices/appliances including the diagnosis or treatment of any
regardless of intended use, except for Condition which is a complication of a non-
therapeutic shoes(including inserts and/or covered Health Care Service(e.g., Health Care
modifications)for the treatment of severe Services to treat a complication of cosmetic
diabetic foot disease. surgery are not covered).
Assisted Reproductive Therapy(Infertility) Contraceptive medications, devices,
including, but not limited to, associated Services, appliances, or other Health Care Services when
supplies,and medications for In Vitro provided for contraception, except when
Fertilization(IVF); Gamete Intrafallopian indicated as covered, under the adult wellness
Transfer(GIFT)procedures; Zygote benefit, on the Schedule of Benefits (when
Intrafallopian Transfer(ZIFT)procedures; selected b the Group
),p), or otherwise covered in
Artificial Insemination (Al); embryo transport; the"What Is Covered?" section.
surrogate parenting; donor semen and related
costs including collection and preparation;and Cosmetic Services, including any Service to
infertility treatment medication. improve the appearance or self-perception of an
individual(except as covered under the Breast
Autopsy or postmortem examination services, Reconstructive Surgery category), including and
unless specifically requested by BCBSF or without limitation: cosmetic surgery and
Monroe County BOCC. procedures or supplies to correct hair loss or
Complementary or Alternative Medicine skin wrinkling(e.g., Minoxidil, Rogaine, Retin-A),
including, but not limited to, self-care or self-help and hair implants/transplants.
training; homeopathic medicine and counseling;
Ayurvedic medicine such as lifestyle
What Is Not Covered? 3-1
Costs related to telephone consultations,failure for at least one indication, provided the drug
to keep a scheduled appointment, or completion is recognized for treatment of your particular
of any form and/or medical information. cancer in a Standard Reference
Custodial Care and any service of a custodial Compendium or recommended for treatment
of your particular cancer in Medical
nature, including and without limitation: Health Literature. Drugs prescribed for the
Care Services primarily to assist in the activities treatment of cancer that have not been
of daily living; rest homes;home companions or approved for any indication are excluded.
sitters; home parents; domestic maid services;
respite care; and provision of services which are 2. All drugs dispensed to, or purchased by, you
for the sole purposes of allowing a family from a pharmacy. This exclusion does not
member or caregiver of a Covered Person to apply to drugs dispensed to you when:
return to work. a. you are an inpatient in a Hospital,
Dental Care or treatment of the teeth or their Ambulatory Surgical Center, Skilled
supporting structures or gums,or dental Nursing Facility, Psychiatric Facility or a
procedures, including but not limited to: Hospice facility;
extraction of teeth,restoration of teeth with or b. you are in the outpatient department of
without fillings, crowns or other materials, a Hospital;
bridges,cleaning of teeth,dental implants,
dentures, periodontal or endodontic procedures, c. dispensed to your Physician for
orthodontic treatment(e.g., braces), intraoral administration to you in the Physician's
prosthetic devices, palatal expansion devices, office and prior coverage authorization
bruxism appliances, and dental x-rays. This has been obtained(if required);
exclusion also applies to Phase II treatments(as d. you are receiving Home Health Care
defined by the American Dental Association)for according to a plan of treatment and the
TMJ dysfunction. This exclusion does not apply Home Health Care Agency bills us for
to an Accidental Dental Injury and the Child Cleft such drugs, including Self-Administered
Lip and Cleft Palate Treatment Services Prescription Drugs that are rendered in
category as described in the"What Is Covered?" connection with a nursing visit.
section.
3. Any non-Prescription medicines, remedies,
Drugs vaccines, biological products(except
insulin), pharmaceuticals or chemical
1. Prescribed for uses other than the Food and compounds, vitamins, mineral supplements,
Drug Administration(FDA)approved label indications. This exclusion does not apply to fluoride products,over-the-counter drugs,
products,or health foods, except as
any drug that has been proven safe,effective and accepted for the treatment of described in the Preventive Adult Wellness
Services and Preventive Child Health
the specific medical Condition for which the Supervision Services categories of the
drug has been prescribed, as evidenced by "What Is Covered?"section.
the results of good quality controlled clinical
studies published in at least two or more 4. Any drug which is indicated or used for
peer-reviewed full length articles in sexual dysfunction (e.g., Cialis, Levitra,
respected national professional medical Viagra, Caverject). The exception described
journals. This exclusion also does not apply in exclusion number one above does not
to any drug prescribed for the treatment of apply to sexual dysfunction drugs excluded
cancer that has been approved by the FDA under this paragraph.
What Is Not Covered? 3_2
5. Any Self-Administered Prescription Drug not Food and Food Products prescribed or not,
indicated as covered in the "What Is except as covered in the Enteral Formulas
Covered?"section of this Benefit Booklet. subsection of the"What Is Covered?" section.
6. Blood or blood products used to treat Foot Care which is routine,including any Health
hemophilia,except when provided to you Care Service, in the absence of disease. This
for: exclusion includes, but is not limited to: non-
a. emergency stabilization; surgical treatment of bunions;flat feet;fallen
arches;chronic foot strain; trimming of toenails
b. during a covered inpatient stay, or corns,or calluses.
c. when proximately related to a surgical General Exclusions include, but are not limited
procedure. to:
The exceptions to the exclusion for drugs 1. any Health Care Service received prior to
purchased or dispensed by a pharmacy your Effective Date or after the date your
described in subparagraph number two do coverage terminates;
not apply to hemophilia drugs excluded
under this subparagraph. 2. any Service to diagnose or treat any
Condition resulting from or in connection
7. Drugs, which require prior coverage with your job or employment;
authorization when prior coverage
authorization is not obtained. 3. any Health Care Services not within the
service categories described in the"What is
8. Specialty Drugs used to increase height or Covered?"section, any rider, or
bone growth (e.g.,growth hormone)except Endorsement attached hereto, unless such
for Conditions of growth hormone deficiency services are specifically required to be
documented with two abnormally low covered by applicable law;
stimulation tests of less than 10 ng/ml and
one abnormally low growth hormone 4. any Health Care Services provided by a
dependent peptide or for Conditions of Physician or other health care Provider
growth hormone deficiency associated with related to you by blood or marriage;
loss of pituitary function due to trauma, 5. any Health Care Service which is not
surgery,tumors, radiation or disease, or for Medically Necessary as determined by us or
state mandated use as in patients with Monroe County BOCC and defined in this
AIDS. Booklet. The ordering of a Service by a
Continuation of growth hormone therapy will health care Provider does not in itself make
not be covered except for Conditions such Service Medically Necessary or a
associated with significant growth hormone Covered Service;
deficiency when there is evidence of 6. any Health Care Services rendered at no
continued responsiveness to treatment. charge;
(See"What is Covered?"section for
additional information.) 7. expenses for claims denied because we did
not receive information requested from you
Experimental or Investigational Services, regarding whether or not you have other
except as otherwise covered under the Bone coverage and the details of such coverage;
Marrow Transplant provision of the Transplant
Services category.
What Is Not Covered
33
8. any Health Care Services to diagnose or Hearing Aids (external or implantable)and
treat a Condition which,directly or indirectly, Services related to the fitting or provision of
resulted from or is in connection with: hearing aids, including tinnitus maskers,
a) war or an act of war,whether declared batteries, and cost of repair.
or not; Immunizations except those covered under the
b) your participation in, or commission of, Preventive Child Health Supervision Services or
any act punishable by law as a Preventive Adult Wellness Services categories
misdemeanor or felony, or which of the"What Is Covered?" section.
constitutes riot, or rebellion; Maternity Services rendered to a Covered
c) your engaging in an illegal occupation; Person who becomes pregnant as a Gestational
d) Services received at military or Surrogate under the terms of, and in accordance
government facilities; or with, a Gestational Surrogacy Contract or
e) Services received to treat a Condition Arrangement. This exclusion applies to all
arising out of your service in the armed expenses for prenatal, intra-partal, and post-
forces, reserves and/or National Guard; partal Maternity/Obstetrical Care,and Health
Care Services rendered to the Covered Person
f) Services that are not patient-specific, as acting as a Gestational Surrogate.
determined solely by us.
9. Health Care Services rendered because For the definition of Gestational Surrogate and
they were ordered by a court, unless such Gestational Surrogacy Contract see the
Services are Covered Services under this Definitions section of this Benefit Booklet.
Benefit Booklet; and Oral Surgery except as provided under the
10. any Health Care Services rendered by or "What Is Covered?"section.
through a medical or dental department Orthomolecular Therap
y including nutrients,
maintained by or on behalf of an employer, vitamins, and food supplements.
mutual association, labor union,trust, or
similar person or group; or Oversight of a medical laboratory by a
Physician or other health care Provider.
11. Health Care Services that are not direct, "Oversight"as used in this exclusion shall,
hands-on, and patient specific, including, but include, but is not limited to,the oversight of:
not limited to the oversight of a medical
laboratory to assure timeliness, reliability, 1. the laboratory to assure timeliness,
and/or usefulness of test results, or the reliability, and/or usefulness of test results;
oversight of the calibration of laboratory 2. the calibration of laboratory machines or
machines,equipment, or laboratory testing of laboratory equipment;
technicians.
3. the preparation, review or updating of any
Genetic screening, including the evaluation of protocol or procedure created or reviewed
genes to determine if you are a carrier of an by a Physician or other health care Provider
abnormal gene that puts you at risk fora in connection with the operation of the
Condition, except as provided under the laboratory; and
Preventive Adult Wellness Services and
Preventive Child Health Supervision Services 4. laboratory equipment or laboratory
categories of the"What Is Covered?" section. personnel for any reason.
What Is Not Covered? 3-4
Personal Comfort, Hygiene or Convenience Sexual Reassignment,or Modification
Items and Services deemed to be not Medically Services including, but not limited to, any Health
Necessary and not directly related to your Care Services related to such treatment, such
treatment including, but not limited to: as psychiatric Services.
1. beauty and barber services; Smoking Cessation Programs including any
2. clothing including support hose; service to eliminate or reduce the dependency
3. radio and television; on, or addiction to,tobacco, including but not
limited to nicotine withdrawal programs and
4. guest meals and accommodations; it
5. telephone charges; nicotine products(e.g.,gum,transdermal
patches, etc.).
6. take-home supplies;
7. travel expenses(other than Medically Sports-Related devices and services used to
Necessary Ambulance Services); affect performance primarily in sports-related
activities;all expenses related to physical
8. motel/hotel accommodations; conditioning programs such as athletic training,
9. air conditioners,furnaces, air filters, air or bodybuilding, exercise,fitness, flexibility, and
water purification systems,water softening diversion or general motivation.
systems, humidifiers,dehumidifiers,vacuum
cleaners or any other similar equipment and Training and Educational Programs, or
devices used for environmental control or to materials, including, but not limited to programs
enhance an environmental setting; or materials for pain management and
10. hot tubs, Jacuzzis, heated spas, pools,or vocational rehabilitation, except as provided
memberships to health clubs;
under the Diabetes Outpatient Self Management
category of the"What Is Covered?" section.
11, heating pads, hot water bottles, or ice packs;
12. physical fitness equipment; Travel or vacation expenses even if prescribed
13. hand rails and grab bars;and or ordered by a Provider.
14. Massages except as covered in the"What Is Volunteer Services or Services which would
Covered?"section of this Booklet. normally be provided free of charge and any
charges associated with Deductible,
Private Duty Nursing Care rendered at any Coinsurance, or Copayment(if applicable)
location. requirements which are waived by a health care
Rehabilitative Therapies provided on an Provider.
inpatient or outpatient basis, except as provided Weight Control Services including any service
in the Hospital, Skilled Nursing Facility, Home to lose,gain, or maintain weight, including
Health Care,and Outpatient Cardiac, without limitation: any weight control/loss
Occupational, Physical, Speech, Massage program; appetite suppressants; dietary
Therapies and Spinal Manipulations categories regimens;food or food supplements; exercise
of the"What Is Covered?" section. programs;equipment;whether or not it is part of
Rehabilitative Therapies provided for the a treatment plan for a Condition.
purpose of maintaining rather than improving
your Condition are also excluded. Wigs and/or cranial prosthesis.
Reversal of Voluntary, Surgically-Induced
Sterility including the reversal of tubal ligations
and vasectomies.
What Is Not Covered? 3-5
Section 4: Medical Necessity
In order for Health Care Services to be covered 1. staying in the Hospital because
under this Booklet, such Services must meet all arrangements for discharge have not been
of the requirements to be a Covered Service, completed;
including being Medically Necessary,as defined 2. use of laboratory,x-ray, or other diagnostic
by this Benefit Booklet. testing that has no clear indication, or is not
It is important to remember that any review of expected to alter your treatment;
Medical Necessity we undertake is solely for the
3. staying in the Hospital because supervision
purposes of determining coverage, benefits, or
in the home, or care in the home, is not
payment under the terms of this Booklet and not available or inconvenient; or being
for the purpose of recommending or providing hospitalized for any Service which could
medical care, In conducting a review of Medical have been provided adequately in an
Necessity, BCBSF may review specific medical alternate setting (e.g., Hospital outpatient
facts or information pertaining to you. Any such department); or
review, however, is strictly for the purpose of
determining whether a Health Care Service 4. inpatient admissions to a Hospital, Skilled
provided or proposed meets the definition of Nursing Facility, or any other facility for the
Medical Necessity in this Booklet. In applying purpose of Custodial Care, convalescent
the definition of Medical Necessity in this care,or any other Service primarily for the
Booklet to a specific Health Care Service, convenience of the patient or his or her
coverage and payment guidelines then in effect family members or a Provider.
may be applied by BCBSF. Note: Whether or not a Health Care Service
All decisions that require or pertain to is specifically listed as an exclusion,the fact
independent professional medical/clinical that a Provider may prescribe, recommend,
judgement or training, or the need for medical approve,or furnish a Health Care Service
services, are solely your responsibility and that does not mean that the Service is Medically
of your treating Physicians and health care Necessary(as defined by this Benefit
Providers. You and your Physicians are Booklet)or a Covered Service. Please refer
responsible for deciding what medical care to the"Definitions" section for the
should be rendered or received and when that definitions of"Medically Necessary"or
care should be provided. Monroe County BOCC "Medical Necessity".
is ultimately responsible for determining whether
expenses incurred for medical care are covered
under this Booklet. In making coverage
decisions, neither BCBSF nor Monroe County
BOCC will be deemed to participate in or
override your decisions concerning your health
or the medical decisions of your health care
Providers.
Examples of hospitalization and other Health
Care Services that are not Medically Necessary
include, but are not limited to:
Medical Necessity 4.1
Section 5: Understanding Your Share of Health Care
Expenses
This section explains what your share of the Benefits for the specific Covered Services which
health care expenses will be for Covered are subject to a Copayment. Listed below is a
Services you receive. In addition to the brief description of some of the Copayment
information
ton explained in this section, it is requirements that may apply to your plan. If the
important that you refer to your Schedule of Allowed Amount or the Provider's actual charge
Benefits to determine your share of the cost with for a Covered Service rendered is less than the
regard to Covered Services. Copayment amount,you must pay the lesser of
the Allowed Amount or the Provider's actual
Deductible Requirement charge for the Covered Service.
Individual Deductible 1. Office Services Copayment:
This amount,when applicable, must be satisfied If your plan is a Copayment plan, the
by you and each of your Covered Dependents Copayment for Covered Services rendered
in the office(when applicable)must be
each Benefit Period, before any payment will be satisfied by you,for each office Service
made by the Group Health Plan. Only those before any payment will be made. The
charges indicated on claims received for office Services Copayment applies
Covered Services will be credited toward the regardless of the reason for the office visit
individual Deductible and only up to the and applies to all Covered Services
applicable Allowed Amount. Please see your rendered in the office, with the exception of
Schedule of Benefits for more information. Durable Medical Equipment, Medical
Family Deductible Pharmacy, Prosthetics,and Orthotics.
If your plan includes a family Deductible, after Generally, if more than one Covered Service
the family Deductible has been met by your that is subject to a Copayment is rendered
family, neither you nor your Covered during the same office visit, you will be
Dependents will have any additional Deductible responsible for a single Copayment which
responsibility for the remainder of that Benefit will not exceed the highest Copayment
Period. The maximum amount that any one specified in the Schedule of Benefits for the
Covered Person in your family can contribute particular Health Care Services rendered.
toward the family Deductible, if applicable, is the 2. Inpatient Facility Copayment:
amount applied toward the individual Deductible.
Please see your Schedule of Benefits for more The inpatient facility Copayment must be
information. satisfied by you,for each inpatient
admission to a Hospital, Psychiatric Facility,
Copayment Requirements or Substance Abuse Facility, before any
payment will be made for any claim for
Covered Services rendered by certain Providers inpatient Covered Services. The inpatient
or at certain locations or settings will be subject facility Copayment applies regardless of the
to a Copayment requirement. This is the dollar reason for the admission, and applies to all
amount you have to pay when you receive these inpatient admissions to a Hospital,
Services. Please refer to your Schedule of Psychiatric Facility or Substance Abuse
understanding Your Share of Health Care Expenses 5-1
Facility in or outside the state of Florida. Coinsurance Requirements
Additionally, you will be responsible for out-
of-pocket expenses for Covered Services All applicable Deductible or Copayment amounts
provided by Physicians and other health must be satisfied before any portion of the
Allowed Amount will be paid for Covered
care professionals for inpatient admissions. Services. For Services that are subject to
Note: Inpatient facility Copayments may Coinsurance,the Coinsurance percentage of the
vary depending on the facility chosen. applicable Allowed Amount you are responsible
(Please see the Schedule of Benefits for for is listed in the Schedule of Benefits.
more information).
3. Outpatient Facility Copayment: Out-of-Pocket Maximums
The outpatient facility Copayment must be Individual out-of-pocket maximum
satisfied by you,for each outpatient visit to a
Hospital, Ambulatory Surgical Center, Once you have reached the individual out-of-
Independent Diagnostic Testing Facility, pocket maximum amount listed in the Schedule
Psychiatric Facility or Substance Abuse of Benefits, you will have no additional out-of-
Facility, before any payment will be made for pocket responsibility for the remainder of that
any claim for outpatient Covered Services. Benefit Period and we will pay 100 percent of
The Outpatient Facility Copayment applies the Allowed Amount for Covered Services
regardless of the reason for the visit, and rendered during the remainder of that Benefit
applies to all outpatient visits to a Hospital, Period.
Psychiatric Facility or Substance Abuse Family out-of-pocket maximum
Facility in or outside the state of Florida.
Additionally, you will be responsible for out- If your plan includes a family out-of-pocket
of-pocket expenses for Covered Services maximum,once your family has reached the
provided by Physician and other healthcare family out-of-pocket maximum amount listed in
professionals. the Schedule of Benefits, neither you nor your
Note: Outpatient facility Copayments may covered family members will have any additional
vary depending on the facility chosen. out-of-pocket responsibility for the remainder of
(Please see the Schedule of Benefits for that Benefit Period and we will pay 100 percent
more information). of the Allowed Amount for Covered Services
rendered during the remainder of that Benefit
4. Emergency Room Facility Copayment: Period. The maximum amount any one Covered
The emergency room facility Copayment Person in your family can contribute toward the
applies regardless of the reason for the visit, family out-of-pocket maximum, if applicable, is
is in addition to the applicable Coinsurance the amount applied toward the individual out-of-
amount, and applies to emergency room pocket maximum. Please see your Schedule of
facility Services in or outside the state of Benefits for more information.
Florida. The emergency room facility Note: The Deductible, any applicable
Copayment must be satisfied by you for
each visit. If you are admitted to the Copayments and Coinsurance amounts will
Hospital as an inpatient at the time of the accumulate toward the out-of-pocket maximums.
emergency room visit, the emergency room Any benefit penalty reductions, non-covered
facility Copayment will be waived, but you charges or any charges in excess of the Allowed
will still be responsible for the inpatient Amount will not accumulate toward the out-of-
facility Copayment. pocket maximums. If the Group has purchased
Prescription Drug coverage, any applicable Cost
Understanding Your Share of Health Care Expenses 5-2
Share under the Prescription Drug coverage,will given for Health Care Services which would
not apply to the Deductible or the out-of-pocket have been Covered Services under this
maximums under this Booklet. Booklet.
Prior Coverage Credit 4. Prior coverage credit under this Booklet only
applies at the initial enrollment of the entire
You will be given credit for the satisfaction or Group. You and/or Monroe County BOCC
partial satisfaction of any Deductible and are responsible for providing BCBSF with
Coinsurance maximums met by you under a any information necessary for BCBSF to
prior group insurance, blanket insurance, or apply this prior coverage credit.
franchise insurance or group Health
Maintenance Organization (HMO)policy or plan Benefit Maximum Carryover
maintained by Monroe County BOCC if the
coverage provided hereunder replaces such a If immediately before the Effective Date of the
policy or plan.This provision only applies if the coverage under this Benefit Booklet, you were
prior group insurance, blanket insurance, covered under a prior Monroe County BOCC
franchise insurance, HMO or plan coverage was group plan insured or administered by BCBSF,
in effect immediately preceding the Effective amounts applied to your benefit maximums
Date of the coverage provided under this Benefit under the prior group plan, will be applied
Booklet. This provision is only applicable for you toward your benefit maximums under this
during the initial Benefit Period of coverage Booklet.
under this Benefit Booklet and the following
rules apply: Additional Expenses You Must Pay
1. Prior Coverage Credit for Deductible: In addition to your share of the expenses
For the initial Benefit Period of coverage described above, you are also responsible for:
under this Benefit Booklet only,charges 1, any applicable Copayments;
credited towards your Deductible
requirement under the prior policy or plan, 2. expenses incurred for non-covered
for Services rendered during the - Services;
e 90 day
period immediately preceding the Effective 3. charges in excess of any maximum benefit
Date of the coverage under this Benefit limitation listed in the Schedule of Benefits
Booklet,will be credited to the Deductible (e.g., the Benefit Period maximums);
requirement under this Booklet.
4. charges in excess of the Allowed Amount for
2. Prior Coverage Credit for Coinsurance: Covered Services rendered by Providers
Charges credited by Monroe County who have not agreed to accept the Allowed
BOCC's prior policy or plan,towards your Amount as payment in full;
Coinsurance Maximum, for Services 5. any benefit reductions;
rendered during the 90-day period
immediately preceding the Effective Date of 6. payment of expenses for claims denied
coverage under this Benefit Booklet, will be because we did not receive information
requested from you regarding whether or not
credited to your out-of-pocket maximum
under this Booklet. you have other coverage and the details of
such coverage; and
3. Prior coverage credit towards the Deductible
or out-of-pocket maximums will only be charges for Health Care Services which are
excluded.
Understanding Your Share of Heafth Care Expenses 5-3
Additionally, you are responsible for any
contribution amount required by Monroe County
BOCC.
How Benefit Maximums Will Be
Credited
Only amounts actually paid for Covered
Services will be credited towards any applicable
benefit maximums. The amounts paid which are
credited towards your benefit maximums will be
based on the Allowed Amount for the Covered
Services provided.
Understanding Your Share of Health Care Expenses 54
Section 6: Physicians, Hospitals and Other Provider
Options
Introduction continuing a relationship with a Family Physician
It is important for you to understand how the allows the physician to become knowledgeable
Provider you select and the setting in which you about you and your family's health history. A
receive Health Care Services affects how much Family Physician can help you determine when
you are responsible for paying under this you need to visit a specialist and also help you
Booklet. This section, along with the Schedule find one based on their knowledge of you and
! of Benefits, describes the health care Provider your specific healthcare needs. Types of Family
Physicians are Family Practitioners, General
options available to you and the payment rules practitioners, Internal Medicine doctors and
for Services you receive.
Pediatricians. Additionally, care rendered by
As used throughout this section"out-of-pocket Family Physicians usually results in lower out-of-
expenses"or"out-of-pocket"refers to the pocket expenses for you. Whether you select a
amounts you are required to pay including any Family Physician or another type of Physician to
applicable Copayments,the Deductible and/or render Health Care Services, please remember
Coinsurance amounts for Covered Services. that using In-Network Providers may result in
lower out-of-pocket expenses for you. You
You are entitled to preferred provider type should always determine whether a Provider is
benefits when you receive Covered Services In-Network or Out-of-Network prior to receiving
from In-Network Providers. You are entitled to Services to determine the amount you are
! traditional program type benefits at the point of responsible for paying out-of-pocket.
service when you receive Covered Services
from Traditional Program Providers or Location of Service
BlueCard®(Out-of-State)Traditional Program
Providers, in conformity with Section 7: In addition to the participation status of the
BlueCard®(Out-of-State)Program. Provider,the location or setting where you
receive Services can affect the amount you pay.
Provider Participation Status For example,the amount you are responsible for
paying out-of-pocket will vary whether you
With BlueOptions, you may choose to receive receive Services in a Hospital, a Provider's
Services from any Provider. However, you may office,or an Ambulatory Surgical Center.
I
be able to lower the amount you have to pay for Please refer to your Schedule of Benefits for
Covered Services by receiving care from an In- specific information regarding your out-of-pocket
Network Provider. Although you have the option expenses for such situations. After you and
to select any Provider you choose, you are your Physician have determined the plan of
encouraged to select and develop a relationship treatment most appropriate for your care, you
with an In-Network Family Physician. There are should refer to the"What Is Covered?" section
several advantages to selecting a Family and your Schedule of Benefits to find out if the
Physician. Family Physicians are trained to specific Health Care Services are covered and
provide a broad range of medical care and can how much you will have to pay. You should also
be a valuable resource to coordinate your consult with your Physician to determine the
overall healthcare needs. Developing and most appropriate setting based on your health
care and financial needs.
Physicians,Hospitals and Other Provider Options 6-1
i
i
To verify if a Provider is In-Network benefit plan,the Provider is considered Out-of-
for your plan you can: Network.
1. If in Florida, review your current BlueOptions
Provider Directory;
2. If in Florida, access the BlueOptions
Provider directory at BCBSF's web-site at
www.bcbsfl.com; and/or
3. If outside of Florida,access the on-line
BlueCard®Doctor and Hospital Finder at
www.bcbs.com;and/or
4. Call the customer service phone number in
this Booklet or on your Identification Card to
search for PPO providers.
Please remember that changes to Provider
network participation can occur at any time.
Consequently, it is your responsibility to
determine whether a specific Provider is In-
Network at the time you receive Covered
Services.
In-Network Providers
When you use In-Network Providers,your out-
of-pocket expenses for Covered Services may
be lower. Payment will be based on the Allowed
Amount and your share of the cost will be at the
In-Network benefit level listed in the Schedule of
Benefits.
Out-of-Network Providers
When you use Out-of-Network Providers your
out-of-pocket expenses for Covered Services
will be higher. We will base our payment on the
Allowed Amount at the Coinsurance percentage
listed in the Schedule of Benefits. Further, if the
Out-of-Network Provider is a Traditional
Program Provider or a BlueCard®(Out-of-State)
Traditional Program Provider, our payment to
such Provider may be under the terms of that
Provider's contract. If your Schedule of Benefits
and BlueOptions Provider directory do not
include a Provider as In-Network under your
Physicians,Hospitals and Other Provider Options 6.2
In-Network Out-of-Network
What expenses • Any applicable Copayments, Deductible(s)and/or Coinsurance requirements;
are you Expenses for Services which are not covered;
responsible for • Expenses for Services in excess of any benefit maximum limitations;
paying? • Expenses for claims denied because we did not receive information
requested from you regarding whether or not you have other coverage and
the details of such coverage; and
• Expenses for Services which are excluded.
Who is • The Provider will file the claim • You are responsible for filing the
responsible for for you and payment will be claim and payment will be made
filing your made directly to the Provider. directly to the Covered Plan
claims? Participant. If you receive Services
from a Provider who participates in
our Traditional Program or is a
BlueCard®(Out-of-State)Traditional
Program Provider, the Provider will
file the claim for you. In those
instances payment will be made
directly to the Provider.
Can you be billed • NO. You are protected from • YES. You are responsible for paying
the difference being billed for the difference in the difference between what we pay
between what the the Allowed Amount and the and the Provider's charge. However,
Provider is paid Provider's charge when you use if you receive Services from a
and the Provider's In-Network Providers. The Provider who participates in our
charge? Provider will accept the Allowed Traditional Program,the Provider will
Amount as payment in full for accept our Allowed Amount as
Covered Services except as payment in full for Covered Services
otherwise permitted under the since such Traditional Program
terms of the Provider's contract Providers have agreed not to bill you
and this Booklet. for the difference. Further, under the
BlueCard®(Out-of-State) Program,
when you receive Covered Services
from a BlueCard®(Out-of-State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In-Network or Out-of-Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians,Hospitals and Other Provider Options 6-3
Physicians admits to by contacting the Physician's office.
This will provide you with information that will
When you receive Covered Services from a help you determine a portion of what your out-of-
Physician you will be responsible for a pocket costs may be in the event you are
Copayment and/or the Deductible and the hospitalized.
applicable Coinsurance. Several factors will
determine your out-of-pocket expenses including Refer to your Schedule of Benefits to determine ,
your Schedule of Benefits,whether the the applicable out-of-pocket expenses you are
Physician is In-Network or Out-of-Network, the
responsible for paying for Hospital Services.
location of service, the type of Service rendered, Specialty Pharmacy
and the Physician's specialty.
Certain medications, such as injectable, oral,
Remember that the location or setting where a inhaled and infused therapies used to treat
Service is rendered can affect the amount you complex medical Conditions are typically more
are responsible for paying out-of-pocket. After difficult to maintain, administer and monitor
you and your Physician have determined the when compared to traditional Drugs. Specialty
plan of treatment most appropriate for your care, Drugs may require frequent dosage
you should refer to the Schedule of Benefits and adjustments,special storage and handling and
consult with your Physician to determine the may not be readily available at local pharmacies
most appropriate setting based on your health or routinely stocked by Physicians'offices,
care and financial needs. mostly due to the high cost and complex
Refer to your Schedule of Benefits to determine
handling they require.
the applicable Copayments,Coinsurance Using the Specialty Pharmacy to provide these
percentage and/or Deductible amount you are Specialty Drugs should lower the amount you
responsible for paying for Physician Services. have to pay for these medications, while helping
to preserve your benefits.
Hospitals
Other Providers
Each time you receive inpatient or outpatient
Covered Services at a Hospital, in addition to With BlueOptions you have access to other
any out-of-pocket expenses related to Physician Providers in addition to the ones previously
Services, you will be responsible for out-of- described in this section. Other Providers
pocket expenses related to Hospital Services. include facilities that provide alternative
outpatient settings or other persons and entities
In-Network Hospitals have been divided into two that specialize in a specific Service(s). While
groups that are referred to as"options" on the these Providers may be recognized for payment,
Schedule of Benefits. The amount you are they may not be included as In-Network
responsible for paying out-of-pocket is different Providers for your plan. Additionally, all of the
for each of these options. Remember that there Services that are within the scope of certain
are also different out-of-pocket expenses for Providers' licenses may not be Covered
Out-of-Network Hospitals. Services under this Booklet. Please refer to the
"What Is Covered?"and"What Is Not Covered?"
Since not all Physicians admit patients to every sections of this Booklet and your Schedule of
Hospital, it is important when choosing a Benefits to determine your out-of-pocket
Physician that you determine the Hospitals expenses for Covered Services rendered by
where your Physician has admitting privileges. these Providers.
You can find out what Hospitals your Physician
Physicians,Hospitals and Other Provider Options 6-4
You may be able to receive certain outpatient Hospital, Physician, or dentist and the benefits
Services at a location other than a Hospital. The which have been assigned are for care provided
amount you are responsible for paying for pursuant to section 395.1041, Florida Statutes;
Services rendered at some alternative facilities or 7)is an Ambulance Provider that provides
is generally less than if you had received those transportation for Services from the location
same Services at a Hospital. where an "emergency medical condition",
Remember that the location of service can defined in section 395.002(8) Florida Statutes,
impact the amount you are responsible for first occurred to a Hospital, and the benefits
paying out-of-pocket. After you and your which have been assigned are for transportation
Ian of treatment
to care provided pursuant to section 395.1041,
Physician have determined the
p Florida Statutes. A written attestation of the
most appropriate for your care,you should refer
to the Schedule of Benefits and consult with assignment of benefits may be required.
your Physician to determine the most
appropriate setting based on your health care
and financial needs. When Services are
rendered at an outpatient facility other than a
Hospital there may be an out-of-pocket expense
for the facility Provider as well as an out-of-
pocket expense for other types of Providers.
Assignment of Benefits to Providers
Except as set forth in the last paragraph of this
section, any of the following assignments,or
attempted assignments,by you to any Provider
will not be honored:
• an assignment of the benefits due to you for
Covered Services under this Benefit
Booklet;
• an assignment of your right to receive
payments for Covered Services under this
Benefit Booklet;or
• an assignment of a claim for damage
resulting from a breach, or an alleged
breach of the terms of this Benefit Booklet.
We specifically reserve the right to honor an
assignment of benefits or payment by you to a
Provider who: 1)is In-Network under your plan
of coverage;2)is a NetworkBlue Provider even
if that Provider is not in the panel for your plan of
coverage; 3)is a Traditional Program Provider;
4)is a BlueCard®(Out-of-State)PPO Program
Provider; 5)is a BlueCard®(Out-of-State)
Traditional Program Provider; 6)is a licensed
Physicians,Hospitals and Other Provider Options 6-5
Section 7: BlueCard® (Out-of-State) Program
Providers Outside the State of paragraph one of this section or require a
Florida surcharge,we will then calculate your liability for
any Covered Services in accordance with the
When you obtain Health Care Services from applicable state statute in effect at the time you
BlueCard®participating Providers outside the received your care.
state of Florida,the amount you pay for
Covered Services is calculated on the lower of:
• The billed charges for your Covered
Services,or
• The negotiated price that the on-site Blue
Cross and/or Blue Shield Plan("Host Blue")
passes on to us.
Often, this"negotiated price"will consist of a
simple discount,which reflects the actual price
paid by the Host Blue. But sometimes it is an
estimated price that factors into the actual price
expected settlements,withholds, any other
contingent payment arrangements and non-
claims transactions with your health care
Provider or with a specified group of Providers.
The negotiated price may also be billed
charges reduced to reflect an average
expected savings with your health care
Provider or with a specified group of Providers.
The price that reflects average savings may
result in greater variation(more or less)from
the actual price paid than will the estimated
price. The negotiated price will also be
prospectively adjusted in the future to correct
for over-or underestimation of past prices.
However,the amount you pay is considered a
final price.
i
Statutes in a small number of states may
require the Host Blue to use a basis for
calculating a covered individual's liability for
Covered Services that does not reflect the
entire savings realized, or expected to be
realized, on a particular claim or to add a
surcharge. Should any state statutes mandate
liability calculation methods that differ from the
usual BlueCard®method noted above in
BlueCard(Out-of-State)Program 7-1
i
Section 8: Blueprint for Health Programs
Introduction Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility(as applicable)if we
BCBSF has established(and from time to time have been notified of your admission. For an
establishes)various customer-focused health admission outside of Florida, you or the
education and information programs as well as
benefit utilization management and utilization Hospital, Psychiatric Facility, Substance Abuse
review programs. Under the terms of the ASO Facility or Skilled Nursing Facility(as applicable)
Agreement between BCBSF and Monroe should notify us of the admission. Making sure
County BOCC, BCBSF has agreed to make that we are notified of your admission will enable
these programs available to you. These us to provide you information about the Blueprint
programs,collectively called the Blueprint for for Health Programs available to you. You or
Health Programs,are designed to 1)provide you the Hospital, Psychiatric Facility, Substance
with information that will help you make more Abuse Facility or Skilled Nursing Facility(as
informed decisions about your health, 2)help applicable)may notify us of your admission by
facilitate the management and review of calling the toll free customer service number on
coverage and benefits provided under this your ID card.
Booklet and 3)present opportunities, as
explained below,to mutually agree upon Out-of-Network
alternative benefits or payment alternatives for
cost-effective medically appropriate Health Care For admissions to an Out-of-Network Hospital,
Services. Some BluePrint For Health Psychiatric Facility, Substance Abuse Facility or
Programs may not be available outside the Skilled Nursing Facility, you or the Hospital,
state of Florida. Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility should notify BCBSF of
Admission Notification the admission. Notifying BCBSF of your
admission will enable BCBSF to provide you
The admission notification requirements vary information about the Blueprint for Health
depending on whether you are admitted to a Programs available to you. You or the Hospital
Hospital, Psychiatric Facility, Substance Abuse may notify BCBSF of your admission by calling
Facility or Skilled Nursing Facility which is In- the toll-free customer service number on your ID
Network or Out-of-Network. card.
In-Network Inpatient Facility Program
Under the admission notification requirement, Under the inpatient facility program,we may
we must be notified of all inpatient admissions review Hospital stays, Hospice, Inpatient
(i.e., elective, planned, urgent or emergency)to Rehabilitation, LTAC and Skilled Nursing Facility
In-Network Hospitals, Psychiatric Facilities, (SNF)Services, and other Health Care Services
Substance Abuse Facilities or Skilled Nursing rendered during the course of an inpatient stay
Facilities. While it is the sole responsibility of or treatment program. We may conduct this
review while you are inpatient, after your
the In-Network Provider located in Florida to discharge,or as part of a review of an episode
comply with our admission notification of care when you are transferred from one level
requirements,you should ask the Hospital,
Blueprmt for Health Programs 8-1
of inpatient care to another for ongoing 2. we perform a focused review under the
treatment. The review is conducted solely to focused utilization management program
determine whether we should provide coverage and we determine that a Health Care
and/or payment for a particular admission or Service is not Medically Necessary in
Health Care Services rendered during that accordance with our Medical Necessity
admission. Using our established criteria then in criteria or inconsistent with our benefit
effect,a concurrent review of the inpatient stay guidelines then in effect unless the following
may occur at regular intervals, including in exception applies.
advance of a transfer from one inpatient facility
to another. We will provide notification to your Exception for Certain NetworkBlue Physicians
Physician when inpatient coverage criteria are Certain NetworkBlue Physicians licensed as
no longer met. In administering the inpatient Doctors of Medicine(M.D.)or Doctors of
facility program,we may review specific medical Osteopathy(D.O.)only may bill you for Services
facts or information and assess,among other determined to be not Medically Necessary by
things,the appropriateness of the Services BCBSF under this focused utilization
being rendered,health care setting and/or the management program if, before you receive the
level of care of an inpatient admission or other
Service:
health care treatment program. Any such
reviews by us, and any reviews or assessments a. they give you a written estimate of your
of specific medical facts or information which we financial obligation for the Service;
conduct, are solely for purposes of making
coverage or payment decisions under this
b. they specifically identify the proposed
Benefit Booklet and not for the purpose of Service that BCBSF has determined not to
recommending or providing medical care. be Medically Necessary; and
c. you agree to assume financial responsibility
Provider Focused Utilization for such Service.
Management Program
Certain NetworkBlue Providers have agreed to Prior Coverage Authorization/Pre-
participate in our focused utilization Service Notification Programs
management program. This pre-service review It is important for you to understand our prior
program is intended to promote the efficient
delivery of medically appropriate Health Care coverage authorization programs and how the
Services by NetworkBlue Providers. Under this Provider you select and the type of Service you
we may receive affects these requirements and
program y perform focused prospective ultimately how much you are responsible for
reviews of all or specific Health Care Services
proposed for you. In order to perform the paying under this Benefit Booklet.
review,we may require the Provider to submit to You or your Provider will be required to obtain
us specific medical information relating to Health prior coverage authorization from us for:
Care Services proposed for you. These
NetworkBlue Providers have agreed not to bill, 1. certain Prescription Drugs denoted with a
or collect, any payment whatsoever from you or special symbol in the Medication Guide as
us, or any other person or entity, with respect to requiring prior authorization;
a specific Health Care Service if: 2. advanced diagnostic imaging Services,
1. they fail to submit the Health Care Service such as CT scans, MRIs, MRA and nuclear
for a focused prospective review when imaging;
required under the terms of their agreement
with us;or
Blueprint for Health Programs 8_2
3. Autism Spectrum Disorder; Mental not require prior authorization when
Health; and Substance Dependency purchased from an Out-of-Network Provider
Services; and for delivery to you at home.
4. other Health Care Services that are or may For additional details on how to obtain prior
become subject to a prior coverage coverage authorization, and for a list of
authorization program or a pre-service Prescription Drugs that require prior
notification program as defined and coverage authorization, please refer to the
administered by us. Medication Guide.
Prior coverage authorization requirements vary, 2. In the case of advanced diagnostic
depending on whether Services are rendered by imaging Services such as CT scans, MRIs,
an In-Network Provider or an Out-of-Network MRA and nuclear imaging, it is your sole
Provider, as described below: responsibility to comply with our prior
coverage authorization requirements when
In-Network Providers rendered or referred by an Out-of-Network
It is the In-Network Provider's sole responsibility Provider before the advanced diagnostic
to comply with our prior coverage authorization imaging Services are provided. Your
requirements, and therefore you will not be failure to obtain prior coverage
responsible for any benefit reductions if prior authorization will result in denial of
coverage authorization is not obtained before coverage for such Services.
Medically Necessary Services are rendered. For additional details on how to obtain prior
Once we have received the necessary medical coverage authorization for advanced
documentation from the Provider, we will review diagnostic imaging Services, please call the
the information and make a prior coverage customer service phone number on the back
authorization decision, based on our established of your ID Card.
criteria then in effect. The Provider will be 3. In the case of Autism Spectrum Disorder,
notified of the prior coverage authorization Mental Health, and Substance
decision. Dependency Services under a prior
Out-of-Network Providers coverage authorization or pre-service
notification program, it is your sole
1. In the case of Prescription Drugs denoted responsibility to comply with our prior
with a special symbol in the Medication coverage authorization or pre-service
Guide as requiring prior authorization,it is notification requirements when rendered or
your sole responsibility to comply with our referred by an Out-of-Network Provider,
prior coverage authorization requirements before the Services are provided. Failure
when you use an Out-of-Network Provider to obtain prior coverage authorization
before the Prescription Drug is purchased will result in denial of coverage for such
or administered.Your failure to obtain Services.
prior coverage authorization will result in
denial of coverage for such Prescription 4. In the case of other Health Care Services
Drug, including any Service related to the under a prior coverage authorization or pre-
Prescription Drug or its administration. service notification program, it is your sole
responsibility to comply with our prior
Exception: Self-Administered Prescription coverage authorization or pre-service
Drugs, identified as Specialty Drugs with a notification requirements when rendered or
special symbol in the Medication Guide, do
Blueprmt for Health Programs 8-3
referred by an Out-of-Network Provider, Member Focused Programs
before the Services are provided. Failure
to obtain prior coverage authorization or The Blueprint for Health Programs may include
provide pre-service notification may voluntary programs for certain members. These
result in denial of the claim or application programs may address health promotion,
of a financial penalty assessed at the prevention and early detection of disease,
time the claim is presented for payment chronic illness management programs, case
to us. The penalty applied will be the lesser management programs and other member
of$500 or 20% of the total Allowed Amount focused programs.
of the claim. The decision to apply a penalty Personal Case Management Program
or deny the claim will be made uniformly and
will be identified in the notice describing the The personal case management program
prior coverage authorization and pre-service focuses on members who suffer from a
notification programs. catastrophic illness or injury. In the event you
have a catastrophic or chronic Condition,we
Once the necessary medical documentation has may, in BCBSF's sole discretion, assign a
been received from you and/or the Out-of- Personal Case Manager to you to help
Network Provider, BCBSF or a designated coordinate coverage, benefits, or payment for
vendor,will review the information and make a Health Care Services you receive. Your
prior coverage authorization decision, based on particioation in this program is completely
our established criteria then in effect. You will voluntary.
be notified of the prior coverage authorization
Under the personal case management program,
decision. you may be offered alternative benefits or
BCBSF will provide you information for any Out- payment for cost-effective Health Care Services.
of-Network Health Care Service subject to a These alternative benefits or payments may be
prior coverage authorization or pre-service made available on a case-by-case basis when
notification program, including how you can you meet BCBSF's case management criteria
obtain prior coverage authorization and/or then in effect. Such alternative benefits or
provide the pre-service notification for such payments, if any, will be made available in
Service not already listed here. This information accordance with a treatment plan with which
will be provided to you upon enrollment, or at you, or your representative, and your Physician
least 30 days prior to such Out-of-Network agree to in writing. In addition, Monroe County
Services becoming subject to a prior coverage BOCC will be required to specifically agree to
authorization or pre-service notification program. such treatment plan and the alternative benefits
or payment.
See the"Claims Processing"section for
information on what you can do if prior coverage The fact that certain Health Care Services under
the personal case management program have
authorization is denied.
been provided or payment has been made in no
Note: Prior coverage authorization is not way obligates BCBSF, Monroe County BOCC,
required when Covered Services are provided or the Group Health Plan to continue to provide
for the treatment of an Emergency Medical or pay for the same or similar Services. Nothing
Condition. contained in this section shall be deemed a
waiver of Monroe County BOCC's right to
enforce this Booklet in strict accordance with its
terms. The terms of this Booklet will continue to
Blueprint for Health Programs 8-4
apply, except as specifically modified in writing Please note that the Hospital admission
in accordance with the personal case notification requirement and any Blueprint For
management program rules then in effect. Health Program may be discontinued or
Health Information, Promotion,Prevention
modified at any time without notice to you or
and Illness Management Programs your consent.
These Blueprint for Health Programs may
include health information that supports health
care education and choices for healthcare
issues. These programs focus on keeping you
well, help to identify early preventive measures
of treatment and help covered individuals with
chronic problems to enjoy lives that are as
productive and healthy as possible. These
programs may include prenatal educational
programs and illness management programs for
Conditions such as diabetes,cancer and heart
disease. These programs are voluntary and are
designed to enhance your ability to make
informed choices and decisions for your unique
health care needs. You may call the toll free
customer service number on your ID card for
more information. Your participation in this
program is completely voluntary.
IMPORTANT INFORMATION RELATING TO
BCBSF'S BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain to
independent professional medical/clinical
judgment or training, or the need for medical
services, are solely your responsibility and the
responsibility of your Physicians and other
health care Providers. You and your Physicians
are responsible for deciding what medical care
should be rendered or received, and when and
how that care should be provided. Monroe
County BOCC is ultimately responsible for
determining whether expenses,which have
been or will be incurred for medical care are, or
will be, covered under this Booklet. In fulfilling
this responsibility, neither BCBSF nor Monroe
County BOCC will be deemed to participate in or
override the medical decisions of your health
care Provider.
Bluepnnt for Health Programs g_5
Section 9: Pre-existing Conditions Exclusion Period
Introduction 6. Genetic Information in the absence of a
diagnosis of the Condition;
Generally,there is no coverage under this
Booklet for Health Care Services to treat a 7. routine follow-up care of breast cancer after the
Pre-existing Condition, or Conditions arising person was determined to be free of breast
from a Pre-existing Condition, until you have cancer;
been continuously covered under this 8. Conditions arising from domestic violence; or
Booklet for a 12-month period. This 12-
month Pre-existing Condition exclusionary 9• inherited diseases of amino acid, organic acid,
period begins on the first day of the Waiting carbohydrate or fat metabolism as well as
Period if you are an initial enrollee; or your malabsorption originating from congenital
Effective Date of coverage under the Booklet defects present at birth or acquired during the
if you are a special or annual enrollee. This neonatal period.
exclusionary period also applies to any
Genetic Information, as used above, means
prescription drug that is prescribed in information about genes, gene products,and
connection with a Pre-existing Condition. inherited characteristics that may derive from the
This Pre-existing Condition exclusionary individual or a family member. This includes
period does not apply to: information regarding carrier status and information
1. the Covered Employee and each derived from laboratory tests that identify mutations
Covered Dependent who was covered in specific genes or chromosomes, physical medical
under the Group's prior medical plan on examinations,family histories, and direct analysis of
the date immediately preceding the genes or chromosomes.
Effective Date of coverage under this Pre-existing Condition Definition
Booklet;
2. you if you were enrolled during the Initial A Pre-existing Condition means any Condition
Enrollment Period prior to the Effective related to a physical or mental Condition, regardless
of the cause of the Condition, for which medical
Date of the Group; advice, diagnosis, care,or treatment was
3. you when the Group has elected to recommended or received during the six-month
waive, in writing, at the time of Group period immediately preceding:
Application the Pre-existing Conditions 1. the first day of your Waiting Period for initial
exclusionary period for all subsequent enrollees; or
Eligible Employees and/or Eligible 2. your Effective Date of coverage under the
Dependents; Group Health Plan for special and annual
4. any Condition for a Covered Person who enrollees.
is under the age of 19 as of the effective
date of this Benefit Booklet, or if enrolled Reducing the Pre-existing Conditions
thereafter, is under the age of 19 at the Exclusionary Period
time of enrollment; No matter whether you enroll when first eligible or at
5. pregnancy; a later date(such as an Annual Open Enrollment
Period or as a result of Special Enrollment),you
Pre-existing Conditions Exclusion Period 9-1
may be able to reduce or even eliminate the 8. a health plan offered under chapter 89 of Title 5,
Pre-existing Conditions exclusionary period if United States Code;
you have prior Creditable Coverage.
9. a public health plan;
If you are enrolling when you are first eligible
10. a health benefit plan of the Peace Corps;
for coverage and you have no more than a
63 day break in Creditable Coverage as of 11. State Children's Health Insurance Program
your Enrollment Date under this Booklet, (CHIP);
your Pre-existing Conditions exclusionary 12. public health plans established by the federal
period will be reduced by the amount of prior government; or
Creditable Coverage you have.
If, on the other hand, you are enrolling under 13. public health plans established by foreigngovernments.
this Booklet at any other time as allowed
under its terms, such as during an Annual Proving Creditable Coverage
Open Enrollment Period or a Special
Enrollment Period, your Pre-existing You may provide a Prior/Concurrent Coverage
Conditions exclusionary period will be Affidavit or Certification of Creditable Coverage to
reduced by the amount of any Creditable prove the amount of time you were covered under
Coverage you have; provided there is no Creditable Coverage. Prior health insurers and/or
more than a 63 day break in coverage prior group health plans are required to provide a
to your Enrollment Date in this Booklet. certification of Creditable Coverage to you upon
If you have no Creditable Coverage or none termination of your coverage and at any time upon
that can reduce the Pre-existing Conditions request up to 24 months after termination of your
exclusionary period,the full 12-month Pre- prior health coverage. If you do not provide a
existing Conditions exclusionary period will certification, then you must provide some other
apply. evidence of Creditable Coverage such as a copy of
an ID card or health insurance bill from a prior
Creditable Coverage carrier and attest to the amount of time you were
covered under the Creditable Coverage.
Creditable Coverage is health care coverage
that may include any of the following:
1. a group health insurance plan;
2, individual health insurance;
3. Medicare Part A and Part B;
4. Medicaid;
5. benefits to members and certain former
members of the uniformed services and
their dependents;
6. a medical care program of the Indian
Health Service or of a tribal organization;
7. a State health benefits risk pool;
Pre-existing Conditions Exclusion Period g 2
i
Section 10: Eligibility for Coverage
Each employee or other individual who is eligible the 60"'day of continuous service or
to participate in the Monroe County Group Waiting Period.
Health Plan, and who meets and continues to Monroe County BOCC's coverage eligibility
meet the eligibility requirements described in this classifications may be expanded to include:
Booklet, shall be entitled to apply for coverage
under this Booklet. These eligibility 1. retired employees;
requirements are binding upon you and/or your 2. Constitutional Officers and their Employees;
eligible family members. No changes in the
eligibility requirements will be permitted except 3. additional job classifications;
as permitted by Monroe County BOCC. 4. employees of affiliated or subsidiary
Acceptable documentation may be required as companies of Monroe County BOCC; and
proof that an individual meets and continues to
meet the eligibility requirements such as a court 5. other individuals as determined by Monroe
i County BOCC.
order naming the Eligible Employee as the legal
guardian or appropriate adoption documentation Monroe County BOCC shall have sole discretion
described in the"Enrollment and Effective Date concerning the expansion of eligibility
of Coverage"section. classifications.
Eligibility Requirements for Covered Eligibility Requirements for
Plan Participants Dependent(s)
In order to be eligible to enroll as a Covered An individual who meets the eligibility criteria
Plan Participant, an individual must be an specified below is an Eligible Dependent and is
Eligible Employee or Eligible Retiree. An eligible to apply for coverage under this Booklet:
Eligible Employee must meet each of the 1. The Covered Employee/Retiree's spouse
following requirements:
under a legally valid existing marriage under
1. The employee must be a bona fide Federal Law.
employee of a Monroe County Employer
participating in the Monroe County Group 2. The Covered Employee/Retiree's natural,
Health Plan; newborn,adopted, Foster, or step children)
(or a child for whom the Covered Employee
2. The employee must be actively working 25 has been court-appointed as legal guardian
hours or more per week on a regular basis; or legal custodian)who has not reached the
3. The employee must have completed the end of the Calendar Year in which he or she
applicable Waiting Period of 60 days of reaches age 26(or in the case of a Foster
continuous service; and Child, is no longer eligible under the Foster
4. The employee must meet any additional Child Program), regardless of the dependent
eligibility requirement(s)required by Monroe child's student or marital status, financial
County BOCC. dependency on the Covered Employee,
whether the dependent child resides with the
Note: Employees and qualified Dependents are Covered Employee, or whether the
eligible for coverage on the day following
Eligibility For Coverage 10_1
dependent child is eligible for or enrolled In Handicapped Children
any other group health plan. In the case of a handicapped dependent child,
3. The newborn child of a Covered Dependent such child is eligible to continue coverage as a
child who has not reached the end of the Covered Dependent, beyond the age of 30, if
Calendar Year in which he or she becomes the child is:
26. Coverage for such newborn child will 1. otherwise eligible for coverage under the
automatically terminate 18 months after the Group Health Plan;
birth of the newborn child.
2. incapable of self-sustaining employment by
Note: If a Covered Dependent child who has reason of mental retardation or physical
reached the end of the Calendar Year in which handicap; and
he or she becomes 26 obtains a dependent of
their own(e.g.,through birth or adoption)such 3. chiefly dependent upon the Covered
newborn child will not be eligible for this Employee for support and maintenance
coverage and the Covered Dependent child will provided that the symptoms or causes of the
also lose his or her eligibility for this coverage. It child's handicap existed prior to the child's
is the Covered Employee's sole responsibility to 30"birthday.
establish that a child meets the applicable This eligibility shall terminate on the last day of
requirements for eligibility. the month in which the dependent child no
This eligibility shall terminate on the last day of longer meets the requirements for extended
the Calendar Year in which the dependent child eligibility as a handicapped child.
reaches age 26. Exception for Students on Medical Leave of
Extension of Eligibility for Dependent Absence from School
Children A Covered Dependent child who is a full-time or
A Covered Dependent child may continue part-time student at an accredited post-
coverage beyond the end of the Calendar Year secondary institution, who takes a physician
in which he or she reaches age 26, provided he certified medically necessary leave of absence
or she is: from school,will still be considered a student for
eligibility purposes under this Booklet for the
1. unmarried and does not have a dependent; earlier of 12 months from the first day of the
2. a Florida resident or a full-time or part-time leave of absence or the date the Covered
student; Dependent would otherwise no longer be eligible
3. not enrolled in any other health coverage for coverage under this Booklet.
policy or group health plan; and
4. not entitled to benefits under Title XVIII of
the Social Security Act unless the child is a
handicapped dependent child.
This eligibility shall terminate on the last day of
the Calendar Year in which the dependent child
reaches age 30.
Eligibildy For Coverage 10-2
Section 11 : Enrollment and Effective Date of Coverage
Eligible Employees, Eligible Retirees, and Employee/Retiree and the employee's spouse
Eligible Dependents may enroll for coverage under a legally valid existing marriage under
according to the provisions below. Federal Law or Domestic Partner.
Any Eligible Employee, Eligible Retiree or Employee/Child(ren)Coverage-This type of
Eligible Dependent who is not properly enrolled coverage provides coverage for the
will not be covered under this Benefit Booklet. Employee/Retiree and the covered child(ren)
Neither BCBSF nor Monroe County BOCC will only
have any obligation whatsoever to any individual Employee/Family Coverage-This type of
who is not properly enrolled. coverage provides coverage for the
Any Employee, Eligible Retiree or Eligible Employee/Retiree and the Covered Dependents.
Dependent who is eligible for coverage under There may be additional contribution amounts
this Booklet may apply for coverage according to for each Covered Dependent based on the
the provisions set forth below. coverage selected by Monroe County BOCC.
Enrollment Forms/Electing Coverage Enrollment Periods
To apply for coverage, you as the Eligible The enrollment periods for applying for coverage
Employee or Eligible Retiree must: are as follows:
1. complete and submit,through Monroe Initial Enrollment Period is the period of time
County BOCC Benefits Office,the during which an Eligible Employee or Eligible
Enrollment Form; Dependent is first eligible to enroll. It starts on
2. provide any additional information needed to the Eligible Employee's or Eligible Dependent's
determine eligibility, at the request of initial date of eligibility and ends no less than 30
BCBSF or Monroe County BOCC Benefits days later.
Office; Annual Open Enrollment Period is the period
3. pay any required contribution; and of time during which each Eligible Employee or
Eligible Retiree is given an opportunity to select
4. complete and submit, through Monroe coverage from among the alternatives included
County BOCC Benefits Office, an in Monroe County BOCC's health benefit
Enrollment Form to add Eligible program. The period is established by Monroe
Dependents. County BOCC, occurs annually, and will take
i
When making application for coverage,you place when specified by Monroe County BOCC.
must elect one of the types of coverage Special Enrollment Period is the 30-day period
available under Monroe County BOCC's of time(unless otherwise noted) immediately
program. Such types may include: following a special circumstance during which an
Employee Only Coverage-This type of Eligible Employee or Eligible Dependent may
coverage provides coverage for the apply for coverage. Special circumstances are
Employee/Retiree only. described in the Special Enrollment Period
Employee/Spouse Coverage-This type of subsection.
coverage provides coverage for the
Enrollment and Effective Date of Coverage �.�
Employee Enrollment Enrollment event, during the Special Enrollment
Period.
An Eligible Employee who fails to enroll during Note: For a Covered Dependent child who has
the Initial Enrollment Period will not be covered reached the end of the Calendar Year in which
and may only enroll under this Benefit Booklet he or she becomes 26 and the Covered
during the next Annual Open Enrollment Period Dependent child obtains a dependent of their
established by Monroe County BOCC, or in the own (e.g.,through birth or adoption), such
case of a Special Enrollment event,during the newborn child will not be eligible for this
Special Enrollment Period. The Effective Date coverage and cannot enroll. Further, such
will be the date specified by Monroe County Covered Dependent child will also lose his or
BOCC. her eligibility for this coverage.
Dependent Enrollment Adopted Newborn Child—To enroll an
adopted newborn child,the Covered Plan
An individual may be added upon becoming an Participant must submit an Enrollment Form
Eligible Dependent of a Covered Plan through Monroe County BOCC Benefits Office to
Participant. Below are special rules for certain BCBSF during the 30-day period immediately
Eligible Dependents. following the date of birth. The Effective Date of
coverage for an adopted newborn child, eligible
Newborn Child—To enroll a newborn child who for coverage, will be the moment of birth,
is an Eligible Dependent,the Covered Plan provided that a written agreement to adopt such
Participant must submit an Enrollment Form to child has been entered into by the Covered Plan
BCBSF through Monroe County BOCC Benefits Office during the 30-day period immediately Participant prior to the birth of such child,
whether or not such an agreement is
following the date of birth. The Effective Date of enforceable. The Covered Plan Participant may
coverage for a newborn child will be the date of be required to provide any information and/or
berth. documents that are deemed necessary in order
If timely notice is given, no additional to administer this provision.
contribution will be charged for coverage of the If timely notice is given, no additional
newborn child for not less than 30 days after the contribution will be charged for coverage of the
birth of the child. If timely notice is not received, adopted newborn child for not less than 30 days
the applicable contribution will be charged from after the birth of the child. If timely notice is not
the date of birth. The applicable contribution for received,the applicable contribution will be
the child will be charged after the initial 30-day charged from the date of birth. The applicable
period in either case. Coverage will not be contribution for the child will be charged after the
denied for a newborn child if the Covered Plan initial 30-day period in either case. Coverage
Participant provides notice to Monroe County will not be denied for an adopted newborn child
BOCC Benefits Office and an Enrollment Form if the Covered Plan Participant provides notice
is received within the 60-day period of the birth to Monroe County BOCC Benefits Office and an
of the child and any applicable contribution is Enrollment Form is received within the 60-day
paid back to the date of birth. period of the birth of the adopted newborn child
If the newborn is not enrolled within sixty days of and any applicable contribution is paid back to
the date of birth, the newborn child will not be the date of birth.
covered, and may only be enrolled under this If the adopted newborn child is not enrolled
Benefit Booklet during an Annual Open within sixty days of the date of birth, the adopted
Enrollment Period,or in the case of a Special newborn child will not be covered, and may only
be enrolled under this Benefit Booklet during an
Enrollment and Effective Date of Coverage 11.2
I
i
Annual Open Enrollment Period, or in the case responsibility of the Covered Plan Participant to
of a Special Enrollment event,during the Special notify BCBSF through Monroe County BOCC
Enrollment Period. Benefits Office if the adoption does not take
i
If the adopted newborn child is not ultimately place. Upon receipt of this notification,we will
placed in the residence of the Covered Plan terminate the coverage of the child as of the
j Participant,there shall be no coverage for the Effective Date of the adopted child upon receipt
adopted newborn child. It is your responsibility of the written notice.
as the Covered Plan Participant notify ant to
i p Monroe If the Covered Plan Participant's status as a
County BOCC Benefits Office within ten foster parent is terminated, coverage will end for j
calendar days of the date that placement was to any Foster Child. It is the responsibility of the I
occur if the adopted newborn child is not placed Covered Plan Participant to notify BCBSF
in your residence. through Monroe County BOCC Benefits Office
Adopted/Foster Children—To enroll an that the Foster Child is no longer in the Covered
adopted or Foster Child,the Covered Plan Plan Participant's care. Upon receipt of this
Participant must submit an Enrollment Form notification,coverage for the child will be
during the 30-day period immediately following terminated on the date the Covered Plan
the date of placement. The Effective Date for an Participant's status as a foster parent
adopted or Foster child(other than an adopted terminated.
newborn child)will be the date such adopted or Marital Status—The Covered Plan Participant
Foster child is placed in the residence of the may apply for coverage of an Eligible Dependent
Covered Plan Participant in compliance with due to a legally valid existing marriage under
applicable law. The Covered Plan Participant Federal Law. To apply for coverage,the
may be required to provide any information Covered Plan Participant must complete the
and/or documents deemed necessary in order to Enrollment Form through Monroe County BOCC
properly administer this section. Benefits Office and forward it to BCBSF. The
In the event Monroe County BOCC Benefits Covered Plan Participant must make application
Office is not notified within 30 days of the date of for enrollment within 30 days of the marriage.
placement,the child will be added as of the date The Effective Date of coverage for an Eligible
of placement so long as Covered Plan Dependent who is enrolled as a result of
Participant provides notice to Monroe County marriage is the date of the marriage.
BOCC Benefits Office, and we receive the Court Order—The Covered Plan Participant
Enrollment Form within 60 days of the may apply for coverage for an Eligible
placement. If the adopted or Foster Child is not Dependent outside of the Initial Enrollment
enrolled within sixty days of the date of Period and Annual Open Enrollment Period if a
placement, the adopted or Foster Child will not court has ordered coverage to be provided for a
be covered, and may only be enrolled under this minor child under their group coverage. To
Benefit Booklet during an Annual Open apply for coverage, the Covered Plan Participant
Enrollment Period, or in the case of a Special must complete an Enrollment Form through
Enrollment event,during the Special Enrollment Monroe County BOCC Benefits Office and
Period. For all children covered as adopted forward it to BCBSF. The Covered Plan
children, if the final decree of adoption is not Participant must make application for enrollment j
Issued, coverage shall not be continued for the within 30 days of the court order. The Effective
proposed adopted Child. Proof of final adoption Date of coverage for an Eligible Dependent who
must be submitted to BCBSF through Monroe is enrolled as a result of a court order is the date
County BOCC Benefits Office. It is the required by the court.
I
Enrollment and Effective Date of Coverage 11.3
Annual Open Enrollment Period health insurance(except in the case of loss
of coverage under a Children's Health
Eligible Employees and/or Eligible Dependents Insurance Program(CHIP)or Medicaid, see
who did not apply for coverage during the Initial #3 below), or COBRA continuation
Enrollment Period or a Special Enrollment coverage that you were covered under at
Period may apply for coverage during an Annual the time of initial enrollment provided that:
Open Enrollment Period. The Eligible Employee
may enroll by completing the Enrollment Form a) when offered coverage under this plan
during the Annual Open Enrollment Period. at the time of initial eligibility, you stated,
in writing,that coverage under a group
The effective date of coverage for an Eligible health plan or health insurance
Employee and any Eligible Dependent(s)will be coverage was the reason for declining
the date established by Monroe County BOCC enrollment; and
Benefits Office. b) you lost your other coverage under a
Eligible Employees who do not enroll or change group health benefit plan or health
their coverage selection during the Annual Open insurance coverage(except in the case
Enrollment Period, must wait until the next of loss of coverage under a CHIP or
Annual Open Enrollment Period, unless the Medicaid, see#3 below)as a result of
Eligible Employee or the Eligible Dependent is termination of employment, reduction in
enrolled due to a special circumstance as the number of hours you work, reaching
outlined in the Special Enrollment Period or exceeding the maximum lifetime of all
subsection of this section. benefits under other health coverage,
the employer ceased offering group
Special Enrollment Period health coverage, death of your spouse,
divorce, legal separation or employer
An Eligible Employee and/or the Employee's contributions toward such coverage was
Eligible Dependent(s)may apply for coverage terminated; and
outside of the Initial Enrollment Period and
Annual Enrollment Period as a result of a special c) you submit the applicable Enrollment
enrollment event. To apply for coverage,the Form to the Group within 30 days of the
Eligible Employee and/or the Employee's date your coverage was terminated
Eligible Dependent(s)must complete the Note, Loss of coverage for failure to pay
applicable Enrollment Form and forward it to the your required contribution/premium on a
Monroe County BOCC Benefits Office within the timely basis or for cause(such as making a
time periods noted below for each special fraudulent claim or an intentional
enrollment event. misrepresentation of a material fact in
An Eligible Employee and/or the Employee's connection with the prior health coverage)is
not a qualifying event for special enrollment.
Eligible Dependent(s)may apply for coverage if
one of the following special enrollment events or
occurs and the applicable Enrollment Form is 2. If when offered coverage under this plan at
submitted to the Monroe County BOCC Benefits the time of initial eligibility,
g' y, you stated, in
Office within the indicated time periods: writing,that coverage under a group health
1. If you lose your coverage under another plan or health insurance coverage was the
group health benefit plan (as an employee reason for declining enrollment; and you get
or dependent), or coverage under other married or obtain a dependent through birth,
adoption or placement in anticipation of
Enrollment and Effective Date of Coverage 11-4
adoption and you submit the applicable
Enrollment Form to the Monroe County
BOCC Benefits Office within 30 days of the
date of the event.
or
3. If you or your Eligible Dependent(s)lose
coverage under a CHIP or Medicaid due to
loss of eligibility for such coverage or
become eligible for the optional state
premium assistance program and you
submit the applicable Enrollment Form to
the Monroe County BOCC Benefits Office
within 60 days of the date such coverage
was terminated or the date you become
eligible for the optional state premium
assistance program.
The Effective Date of coverage for you and your
Eligible Dependents added as a result of a
special enrollment event is the date of the
special enrollment event. Eligible Employees or
Eligible Dependents who do not enroll or change
their coverage selection during the Special
Enrollment Period must wait until the next
Annual Open Enrollment Period(See the
Dependent Enrollment subsection of this section
for the rules relating to the enrollment of Eligible
Dependents of a Covered Plan Participant).
Other Provisions Regarding
Enrollment and Effective Date of
Coverage
Individuals who are rehired as employees of
Monroe County BOCC or any of the
Constitutional Officers or their Employees are
considered newly hired employees for purposes
of this section. The provisions of the Group
Health Plan(which includes this Booklet)which
are applicable to newly hired employees and
their Eligible Dependents(e.g., enrollment,
Effective Dates of coverage, Pre-existing
Condition exclusionary period, and Waiting
Period)are applicable to rehired employees and
their Eligible Dependents.
Enrollment and Effective Date of Coverage t t_g
Section 12: Termination of Coverage
Termination of a Covered Plan 4. last day of the Calendar Year that the
Participant's Coverage Covered Dependent child no longer meets
any of the applicable eligibility requirements;
A Covered Plan Participant's coverage under
this Benefit Booklet will automatically terminate 5. date specified by Monroe County BOCC that
at 12:01 a.m.: the Dependent's coverage is terminated for
cause(see the Termination of Individual
1. on the date the Group Health Plan Coverage for Cause subsection).
terminates;
In the event you as the Covered Plan Participant
2. on the date the ASO Agreement between wish to delete a Covered Dependent from
BCBSF and Monroe County BOCC coverage, an Enrollment Form must be
terminates; forwarded to BCBSF through Monroe County
3. on the last day of the first month that the BOCC Benefits Office.
Covered Plan Participant fails to continue to In the event you as the Covered Plan Participant
meet any of the applicable eligibility wish to terminate a spouse's coverage, (e.g., in
requirements; the case of divorce),you must submit an
4. on the date specified by Monroe County Enrollment Form to Monroe County BOCC, prior
BOCC that the Covered Plan Participant's to the requested termination date or within 10
coverage is terminated for cause(see the days of the date the divorce is final, whichever is
Termination of an Individual Coverage for applicable.
Cause subsection); or
Termination of an Individual's
5. on the date specified by Monroe County Coverage for Cause
BOCC that the Covered Plan Participant's
coverage terminates. In the event any of the following occurs, Monroe
County BOCC may terminate an individual's
Termination of a Covered coverage for cause:
Dependent's Coverage
1. fraud, material misrepresentation or
A Covered Dependent's coverage will omission in applying for coverage or
automatically terminate at 12:01 a.m. on the benefits; or
date: 2. the knowing misrepresentation, omission or
1. the Group Health Plan terminates; the giving of false information on Enrollment
Forms or other forms completed, by or on
2. the Covered Plan Participant's coverage
your behalf.
terminates for any reason;
3. the Dependent becomes covered under an Notice of Termination
alternative health benefits plan which is It is Monroe County BOCC's responsibility to
offered through or in connection with the
Group Health Plan; immediately notify you of your termination or that
of your Covered Dependents for any reason.
Termination of Coverage 12_1
Certification of Creditable Coverage
In the event coverage termin
ates for any reason,
a written certification of Creditable Coverage will
be issued to you.
The certification of Creditable Coverage will
indicate the period of time you were enrolled
under Monroe County BOCC's Group Health
Plan. Creditable Coverage may reduce the
length of any Pre-existing Condition
exclusionary period by the length of time you
had prior Creditable Coverage.
Upon request, another certification of Creditable
Coverage will be sent to you within a 24-month
period after termination of coverage. You may
call the customer service phone number
indicated in this Booklet or on your ID Card to
request the certification.
The succeeding carrier will be responsible for
determining if coverage meets the qualifying
Creditable Coverage guidelines(e.g., no more
than a 63-day break in coverage).
Termination of Coverage 12-2
I
Section 13: Continuing Coverage Under COBRA.
A federal continuation of coverage law, known months)if you or your Covered
as the Consolidated Omnibus Budget Dependent(s)is/are totally disabled (as
Reconciliation Act of 1985(COBRA), as defined by the Social Security Administration
amended, may apply to your Group Health Plan. (SSA))at the time of your termination,
If COBRA applies,you or your Covered reduction in hours or within the first 60 days
Dependents may be entitled to continue of COBRA continuation coverage. The
coverage for a limited period of time, if you meet Covered Person must supply notice of the
the applicable requirements, make a timely disability determination to Monroe County
election, and pay the proper amount required to BOCC Benefits Office within 18 months of
maintain coverage. becoming eligible for continuation coverage
You must contact Monroe County BOCC and no later than 60 days after the SSA's
Benefits Office to determine if you or your determination date.
Covered Dependent(s)are entitled to COBRA 2. Your Covered Dependent(s)may elect to
continuation of coverage. Monroe County continue their coverage for a period not to
BOCC is solely responsible for meeting all of the exceed 36 months in the case of:
obligations under COBRA, including the a) the Covered Plan Participant's
obligation to notify all Covered Persons of their entitlement to Medicare;
rights under COBRA. If you fail to meet your
obligations under COBRA and this Benefit b) divorce or legal separation of the
Booklet, Monroe County BOCC will not be liable Covered Plan Participant;
for any claims incurred by you or your Covered c) death of the Covered Plan Participant;
Dependent(s)after termination of coverage.
d) the employer files bankruptcy(subject to
A summary of your COBRA rights and the bankruptcy court approval); or
general conditions for qualification for COBRA
continuation coverage is provided below. e) a dependent child may elect the 36
month extension if the dependent child
The following is a summary of what you may ceases to be an Eligible Dependent
elect, if COBRA applies to Monroe County under the terms of Monroe County
BOCC and you are eligible for such coverage: BOCC's coverage.
1. You may elect to continue this coverage for Children born to or placed for adoption with the
a period not to exceed 18 months*in the Covered Plan Participant during the continuation
case of: coverage periods noted above are also eligible
a) termination of employment of the for the remainder of the continuation period.
Covered Plan Participant other than for Additional requirements applicable to
gross misconduct;or continuation of coverage under COBRA are set
b) reduced hours of employment of the forth below:
Covered Plan Participant. 1. Monroe County BOCC must notify you of
*Note: You and/or your Covered your continuation of coverage rights under
Dependent(s)are eligible for an 11 month COBRA within 14 days of the event which
extension of the 18 month COBRA creates the continuation option. If coverage
continuation option above(to a total of 29 would be lost due to Medicare entitlement,
Continuing Coverage Under COBRA tg 1
divorce, legal separation or the failure of a An election by a Covered Plan Participant or
Covered Dependent child to meet eligibility Covered Dependent spouse shall be deemed to
requirements,you or your Covered be an election for any other qualified beneficiary
Dependent must notify Monroe County related to that Covered Plan Participant or
BOCC Benefits Office, in writing, within 60 Covered Dependent spouse, unless otherwise
days of any of these events. Monroe specified in the election form.
County BOCC's 14-day notice requirement Note: This section shall not be interpreted to
runs from the date of receipt of such notice. grant any continuation rights in excess of
2. You must elect to continue the coverage those required by COBRA and/or Section
within 60 days of the later of: 4980B of the Internal Revenue Code.
a) the date that the coverage terminates; or Additionally,this Benefit Booklet shall be
deemed to have been modified,and shall be
b) the date the notification of continuation of interpreted, so as to comply with COBRA
coverage rights is sent by Monroe and changes to COBRA that are mandatory
County BOCC. with respect to Monroe County BOCC.
3. COBRA coverage will terminate if you
become covered under any other group
health insurance plan. However,COBRA
coverage may continue if the new group
health insurance plan contains exclusions or
limitations due to a Pre-existing Condition
that would affect your coverage.
4. COBRA coverage will terminate if you
become entitled to Medicare.
5. If you are totally disabled and eligible and
elect to extend your continuation of
coverage, you may not continue such
extension of coverage more than 30 days
after a determination by the Social Security
Administration that you are no longer
disabled. You must inform Monroe County
BOCC Benefits Office of the Social Security
Administration's determination within 30
days of such determination.
6. You must meet all contribution
requirements,and all other eligibility
requirements described in COBRA, and, to
the extent not inconsistent with COBRA, in
the Group Health Plan.
7. COBRA coverage will terminate on the date
Monroe County BOCC ceases to provide
group health coverage to its employees.
Continuing Coverage Under COBRA 13-2
i
Section 14: Conversion Privilege
Eligibility Criteria for Conversion Additionally, you are not entitled to a converted
You are entitled to apply for a BCBSF individual policy if:
insurance conversion policy(hereinafter referred 1. you are eligible for or covered under the
to as a"converted policy' or"conversion policy") Medicare program;
if:
2. you failed to pay,on a timely basis, the
1. you were continuously covered for at least contribution required for coverage under the
three months under the Group Health Plan, Group Health Plan;
and/or under another group policy that
provided similar benefits immediately prior to 3. the Group Health Plan was replaced within
the Group Health Plan', and 31 days after termination by any group
2. your coverage was terminated for any policy,contract, plan, or program, including
a self-insured plan or program,that provides
reason, including discontinuance of the benefits similar to the benefits provided
� Group Health Plan in its entirety and termination of continued coverage under under this Booklet;or
COBRA. 4. a) you fall under one of the following
Notify BCBSF in writing or by telephone if you categories and meet the requirements of
are interested in a conversion policy. Within 14 4.b. below:
days of such notice, BCBSF will send you a I. you are covered under any Hospital,
conversion policy application, premium notice surgical, medical or major medical
and outline of coverage. The outline of policy or contract or under a
coverage will contain a brief description of the prepayment plan or under any other
benefits and coverage, exclusions and plan or program that provides
limitations,and the applicable Deductible(s)and benefits which are similar to the
Coinsurance provisions. benefits provided under this Booklet;
BCBSF must receive a completed application or
for a converted policy, and the applicable ii. you are eligible,whether or not
premium payment,within the 63-day period covered, under any arrangement of
beginning on the date the coverage under coverage for individuals in a group,
the Group Health Plan terminated. If whether on an insured, uninsured,
coverage has been terminated,due to the or partially insured basis,for
non-payment of employee contribution by
Monroe County BOCC, BCBSF must receive benefits similar to those provided
the completed converted policy application under this Booklet;or
and the applicable premium payment within iii. benefits similar to the benefits
the 63-day period beginning on the date provided under this Booklet are
notice was given that the Group Health Plan provided for or are available to you
terminated. pursuant to or in accordance with
In the event BCBSF does not receive the the requirements of any state or
converted policy application and the initial federal law(e.g., COBRA,
premium payment within such 63-day period, Medicaid);and
your converted policy application will be denied
and you will not be entitled to a converted policy.
Conversion Pnvde e
9 14-1
b) the benefits provided under the sources
referred to in paragraph 4.a.i or the
benefits provided or available under the
�
source referred to in paragraph 4.a.ii.
and 4.a.iii.above,together with the
benefits provided by our converted
policy would result in over-insurance in
accordance with our over-insurance
standards, as determined by us.
Neither Monroe County BOCC nor BCBSF
has any obligation to notify you of this
conversion privilege when your coverage
terminates or at any other time. It is your
sole responsibility to exercise this
conversion privilege by submitting a BCBSF
converted policy application and the initial
premium payment to us within 63 days of the
termination of your coverage under this
Benefit Booklet. The converted policy may
be issued without evidence of insurability
and shall be effective the day following the
day your coverage under this Benefit Booklet
terminated.
Note: Our converted policies are not a
continuation of coverage under COBRA or any
other states' similar laws. Coverage and
benefits provided under a converted policy will
not be identical to the coverage and benefits
provided under this Booklet. When applying for
our converted policy, you have two options: 1)a
converted policy providing major medical
coverage meeting the requirements of
627.6675(10) Florida Statutes or 2)a converted
policy providing coverage and benefits identical
to the coverage and benefits required to be
provided under a small employer standard
health benefit plan pursuant to Section
627.6699(12) Florida Statutes. In any event,we
will not be required to issue a converted policy
unless required to do so by Florida law. We
may have other options available to you. Call
the telephone number on your Identification card
for more information.
Conversion Privilege 14-2
Section 15: Extension of Benefits
Extension of Benefits perform those normal day-to-day activities
which you would otherwise perform and you
In the event the Group Health Plan is require regular care and attendance by a
terminated,coverage will not be provided under Physician.
this Benefit Booklet for any Service rendered on
or after the termination date. The extension of 2. In the event you are receiving covered
benefits provisions described below only apply dental treatment as of the termination date
when the entire Group Health Plan is of the Group Health Plan a limited extension
terminated. The extension of benefits described of such covered dental treatment will be
in this section do not apply when your coverage Provided under this Benefit Booklet if:
terminates if the Group Health Plan remains in a) a course of dental treatment or dental
effect. The extension of benefits provisions are procedures were recommended in
subject to all of the other provisions, including writing and commenced in accordance
the limitations and exclusions. with the terms specified herein while you
Note: It is your sole responsibility to provide were covered under the Group Health
acceptable documentation showing that you are Plan;
entitled to an extension of benefits. b) the dental procedures were procedures
1. In the event you are totally disabled on the
for other than routine examinations,
termination date of the Group Health Plan as prophylaxis,x-rays, sealants,or
orthodontic services; and
a result of a specific Accident or illness
incurred while you were covered under this c) the dental procedures were performed
Booklet, as determined by us,a limited within 90 days after the Group Health
extension of benefits will be provided under Plan terminated.
this Benefit Booklet for the disabled This extension of benefits is for Covered
individual only. This extension of benefits is Services necessary to complete the
for Covered Services necessary to treat the dental treatment only. This extension of
disabling Condition only. This extension of benefits will automatically terminate at
benefits will only continue as long as the the end of the 90-day period beginning
disability is continuous and uninterrupted. In on the termination date of the Group
any event,this extension of benefits will Health Plan or on the date you become
automatically terminate at the end of the 12- covered under a succeeding insurance,
month period beginning on the termination health maintenance organization or self-
date of the Group Health Plan. insured plan providing coverage or
For purposes of this section, you will be Services for similar dental procedures.
considered "totally disabled"only if, in our You are not required to be totally
or Monroe County BOCC's opinion,you are disabled in order to be eligible for this
unable to work at any gainful job for which extension of benefits.
you are suited by education,training,or Please refer to the Dental Care category of
experience, and you require regular care the"What Is Covered?" section for a
and attendance by a Physician. You are description of the dental care Services
totally disabled only if, in our or Monroe covered under this Booklet.
County BOCC's opinion, you are unable to
Extension of Benefits t 5_t
3. In the event you are pregnant as of the
termination date of the Group Health Plan, a
limited extension of the maternity expense
benefits included in this Booklet will be
available, provided the pregnancy
commenced while the pregnant individual
was covered under the Group Health Plan,
as determined by us or Monroe County
BOCC. This extension of benefits is for
Covered Services necessary to treat the
pregnancy only. This extension of benefits
will automatically terminate on the date of
the birth of the child. You are not required to
be Totally Disabled in order to be eligible for
this extension of benefits.
Extension of Benefits 15-2
Section 16: The Effect of Medicare Coverage/Medicare
Secondary Payer Provisions
When you become covered under Medicare and disability whose employer has less than 100
continue to be eligible and covered under this employees, retirees and/or their spouses over
Benefit Booklet,coverage under this Benefit the age of 65). Also,if coverage under this
Booklet will be primary and the Medicare Benefit Booklet was primary prior to ESRD
benefits will be secondary, but only to the extent entitlement,then coverage hereunder will
required by law. In all other instances, coverage remain primary for the ESRD coordination
under this Benefit Booklet will be secondary to period. If you become eligible for Medicare due
any Medicare benefits. To the extent the to ESRD,coverage will be provided,as
benefits under this Benefit Booklet are primary, described in this section, on a primary basis for
claims for Covered Services should be filed with 30 months.
BCBSF first.
Under Medicare, Monroe County BOCC MAY Disabled Active Individuals
NOT offer, subsidize, procure or provide a If you are entitled to Medicare coverage
Medicare supplement policy to you. Also, because of a disability other than ESRD,
Monroe County BOCC MAY NOT induce you to Medicare benefits will be secondary to the
decline or terminate your group health insurance benefits provided under this Benefit Booklet
coverage and elect Medicare as primary payer. provided that:
If you become 65 or become eligible for Monroe County BOCC employed at least 100 or
Medicare due to End Stage Renal Disease more full-time or part-time employees on 50% or
("ESRD"), you must immediately notify Monroe more of its regular business days during the
County BOCC Benefits Office. previous Calendar Year. If the Group Health
Plan is a multi-employer plan,as defined by
Individuals With End Stage Renal Medicare, Medicare benefits will be secondary if
Disease at least one employer participating in the plan
If you are entitled to Medicare coverage covered 100 or more employees under the plan
because of ESRD, coverage under this Benefit on 50%or more of its regular business days
Booklet will be provided on a primary basis for during the previous Calendar Year.
30 months beginning with the earlier of: Miscellaneous
1. the month in which you became entitled to
Medicare Part"A" ESRD benefits;or 1. This section shall be subject to, modified (if
necessary)to conform to or comply with,
2. the first month in which you would have and interpreted with reference to the
been entitled to Medicare Part"A" ESRD requirements of federal statutory and
benefits if a timely application had been regulatory Medicare Secondary Payer
made.
provisions as those provisions relate to
If Medicare was primary prior to the time you Medicare beneficiaries who are covered
became eligible due to ESRD,then Medicare under this Benefit Booklet.
will remain primary(i.e., persons entitled due to
The Effect of Medicare coverage/Medicare Secondary Payer Provisions t 6_1
i
2. BCBSF will not be liable to Monroe County
BOCC or to any individual covered under
this Benefit Booklet on account of any
nonpayment of primary benefits resulting
from any failure of performance of Monroe
County BOCC's obligations as described in
this section.
I
i
The Effect of Medicare coverage/Medicare Secondary Payer Provisions 16_2
Section 17: Duplication of Coverage Under Other Health
Plans/Programs
Coordination of Benefits with which the law permits coordination of
benefits;
Coordination of Benefits("COB")is a limitation
4. Medicare,as described in"The Effect of
of coverage and/or benefits to be provided under Medicare Coverage/Medicare Secondary
this Benefit Booklet.
Payer Provisions"section; and
COB determines the manner in which expenses 5. to the extent permitted by law,any other
will be paid when you are covered under more
government sponsored health insurance
than one health plan, program,or policy
providing benefits for Health Care Services. program.
COB is designed to avoid the costly duplication The amount of payment, if any, when benefits
of payment for Covered Services. it is your are coordinated under this section, is based on
responsibility to provide BCBSF and Monroe whether or not the benefits under this Benefit
County BOCC Benefits Office information Booklet are primary. When primary, payment
concerning any duplication of coverage under will be made for Covered Services without
any other health plan, program,or policy you or regard to coverage under other plans. When the
your Covered Dependents may have. This benefits under this Benefit Booklet are not
means you must notify BCBSF and Monroe primary, payment for Covered Services may be
County BOCC Benefits Office in writing if you reduced so that total benefits under all your i
have other applicable coverage or if there is no plans will not exceed 100 percent of the total
other coverage. You may be requested to reasonable expenses actually incurred for
provide this information at initial enrollment, by Covered Services. For purposes of this section,
written correspondence annually thereafter, or in in the event you receive Covered Services from
connection with a specific Health Care Service an In-Network Provider or an Out-of-Network
you receive. If the information is not received, Provider who participates in the Traditional
claims may be denied and you will be Program, "total reasonable expenses'shall
responsible for payment of any expenses related mean the total amount required to be paid to the
to denied claims. Provider pursuant to the applicable agreement
BCBSF or another Blue Cross and/or Blue
Health plans,programs or policies which may be Shield organization has with such Provider. In �
subject to COB include, but are not limited to, the event that the primary
the following which will be referred to as P ry payer's payment
exceeds the Allowed Amount, no payment
I
"plan(s)"for purposes of this section: will be made for such Services.
1. any group or non-group health insurance, The following rules shall be used to establish the
group-type self-insurance, or HMO plan;
order in which benefits under the respective
2. any group plan issued by any Blue Cross plans will be determined:
and/or Blue Shield organization(s);
1. When you are covered as a Covered
3. any other plan, program or insurance policy, Dependent and the other plan covers you as
including an automobile PIP insurance other than a dependent,the Group Health
policy and/or medical payment coverage Plan will be secondary.
Duplication of Coverage Under Other Health Plans/Programs t 7_1
2. When the Group Health Plan covers a The Group Health Plan will not coordinate
dependent child whose parents are not benefits against an indemnity-type policy, an
separated or divorced: excess insurance policy,a policy with
coverage limited to specified illnesses or
a) the plan of the parent whose birthday, accidents, or a Medicare supplement policy.
excluding year of birth,falls earlier in the
6. If you are covered under a COBRA
year will be primary; or
continuation plan as a result of the purchase
b) if both parents have the same birthday, of coverage as provided under the
excluding year of birth,and the other Consolidated Omnibus Budget
plan has covered one of the parents Reconciliation Act of 1985, as amended,
longer than us,the Group Health Plan and also under another group plan,the
will be secondary. following order of benefits applies:
3. When the Group Health Plan covers a a) first,the plan covering the person as an
dependent child whose parents are employee, or as the employee's
separated or divorced: Dependent; and
a) if the parent with custody is not b) second,the coverage purchased under
remarried,the plan of the parent with the plan covering the person as a former
custody is primary; employee,or as the former employee's
b) ifthe parent with custody has remarried, Dependent provided according to the
the plan of the parent with custody is provisions of COBRA.
primary; the stepparent's plan is 7. If the other plan does not have rules that
secondary; and the plan of the parent establish the same order of benefits as
without custody pays last; under this Booklet, the benefits under the
c) regardless of which parent has custody, other plan will be determined primary to the
whenever a court decree specifies the benefits under this Booklet.
parent who is financially responsible for
the child's health care expenses,the Coordination of benefits shall not be permitted
against an indemnity-type policy,an excess
plan of that parent is primary.
insurance policy as defined in Florida Statutes
4. When the Group Health Plan covers a Section 627.635, a policy with coverage limited
dependent child and the dependent child is to specified illnesses or accidents, or a Medicare
also covered under another plan: supplement policy.
a) the plan of the parent who is neither laid
off nor retired will be primary; or Non-Duplication of Government
Programs and Worker's
b) if the other plan is not subject to this Compensation
rule, and if, as a result, such plan does
not agree on the order of benefits,this The benefits under this Booklet shall not
paragraph shall not apply. duplicate any benefits to which you or your
5. When rules 1, 2, 3, and 4 above do not Covered Dependents are entitled to or eligible
establish an order of benefits,the plan which for under government programs(e.g., Medicare,
has covered you the longest shall be Medicaid, Veterans Administration)or Worker's
primary. Compensation to the extent allowed by law, or
under any extension of benefits of coverage
Duplication of Coverage Under Other Health Plans/Programs 17.2
i
under a prior plan or program which may be
provided or required by law.
Duplication of Coverage Under Other Health Plans/Programs 17-3
Section 18: Subrogation
In the event payment is made under this Benefit legal representative shall promptly notify BCBSF
Booklet to you or on your behalf for any claim in in writing of any settlement negotiations prior to
connection with or arising from a Condition entering into any settlement agreement, shall
resulting, directly or indirectly,from an disclose to BCBSF any amount recovered from
intentional act or from the negligence or fault of any person or entity that may be liable,and shall
any third person or entity, Monroe County BOCC not make any distributions of settlement or
and/or the Group Health Plan,to the extent of judgement proceeds without Monroe County
any such payment, shall be subrogated to all BOCC's prior written consent. No waiver,
causes of action and all rights of recovery you release of liability, or other documents executed
have against any person or entity. Such by you without such notice to BCBSF shall be
subrogation rights shall extend and apply to any binding upon Monroe County BOCC.
settlement of a claim, regardless of whether
litigation has been initiated. BCBSF may
recover, on behalf of Monroe County BOCC
and/or the Group Health Plan,the amount of any
payments made on your behalf minus BCBSF or
Monroe County BOCC's pro rata share for any
costs and attorney fees incurred by you in
pursuing and recovering damages. BCBSF may
subrogate, on behalf of Monroe County BOCC
and/or the Group Health Plan,against all money
recovered regardless of the source of the money
including, but not limited to, uninsured motorist
coverage. Although Monroe County BOCC
may, but is not required to, take into
consideration any special factors relating your
specific case in resolving the subrogation claim,
Monroe County BOCC will have the first right of
recovery out of any recovery or settlement
amount you are able to obtain even if you or
your attorney believes that you have not been
made whole for your losses or damages by the
amount of the recovery or settlement.
You must promptly execute and deliver such
instruments and papers pertaining to such
settlement of claims, settlement negotiations,or
litigation as may be requested by BCBSF or
Monroe County BOCC, and shall do whatever is
necessary to enable BCBSF or Monroe County
BOCC to exercise Monroe County BOCC's
subrogation rights and shall do nothing to
prejudice such rights. Additionally, you or your
Subrogation 18_1
Section 19: Right of Reimbursement
I
If any payment under this Benefit Booklet is
made to you or on your behalf with respect to
any injury or illness resulting from the intentional
act, negligence,or fault of a third person or
entity, Monroe County BOCC and/or the Group
Health Plan will have a right to be reimbursed by
you(out of any settlement or judgment proceeds
you recover)one dollar($1.00)for each dollar
paid under the terms of the Group Health Plan
minus a pro rata share for any costs and
attorney fees incurred in pursuing and
recovering such proceeds.
Monroe County BOCC's and/or the Group
Health Plan's right of reimbursement will be in
addition to any subrogation right or claim
available to Monroe County BOCC, and you
must execute and deliver such instruments or
papers pertaining to any settlement or claim,
settlement negotiations, or litigation as may be
requested by BCBSF on behalf of Monroe
County BOCC, and/or the Group Health Plan, to
exercise Monroe County BOCC's and/or the
Group Health Plan's right of reimbursement
hereunder. You or your lawyer must notify us,
by certified or registered mail, if you intend to
claim damages from someone for injuries or
illness. You must do nothing to prejudice
Monroe County BOCC's and/or the Group
Health Plan's right of reimbursement hereunder
and no waiver, release of liability, or other
documents executed by you,without notice to us
and our written consent, acting on behalf of
Monroe County BOCC,will be binding upon
Monroe County BOCC.
Right of Reimbursement g_t
Section 20: Claims Processing
Introduction Post-Service Claims
This section is intended to: How to File a Post-Service Claim
• help you understand what you or your We have defined and described the three types
treating Providers must do, under the terms of claims that may be submitted to us. Our
of this Benefit Booklet, in order to obtain experience shows that the most common type of
payment for expenses for Covered Services claim we will receive from you or your treating j
they have rendered or will render to you; Providers will likely be Post-Service Claims.
and In-Network Providers have agreed to file Post-
provide you with a general description of the Service Claims for Services the render to you.
Y 9 P Y
applicable procedures we will use for In the event a Provider who renders Services to
making Adverse Benefit Determinations, you does not file a Post-Service Claim for such
Concurrent Care Decisions and for notifying Services, it is your responsibility to file it with us.
you when we deny benefits. We must receive a Post-Service Claim within 90
Under no circumstances will we be held days of the date the Health Care Service was
responsible for, nor will we accept liability rendered or, if it was not reasonably possible to
relating to, the failure of your Group Plan's file within such 90-day period,as soon as
sponsor or plan administrator to: 1)comply with possible. In any event, no Post-Service Claim
any applicable disclosure requirements;
will be considered for payment if we do not
2)provide you with a Summary Plan Description receive it at the address indicated on your ID
(SPD); or 3)comply with any other legal Card within one year of the date the Service was
requirements. You should contact your plan rendered unless you were legally incapacitated.
sponsor or administrator if you have questions For Post-Service Claims,we must receive an
relating to your Group Plan's SPD. We are not itemized statement from the health care Provider
your Group Plan's sponsor or plan administrator. for the Service rendered along with a completed
In most cases, a plan's sponsor or plan claim form. The itemized statement must
administrator is the employer who establishes contain the following information:
and maintains the plan. 1. the date the Service was provided;
Types of Claims 2. a description of the Service including any
applicable procedure code(s);
For purposes of this Benefit Booklet, there are
three types of claims: 1) Pre-Service Claims; 3. the amount actually charged by the
2) Post-Service Claims;and 3)Claims Involving Provider;
Urgent Care. It is important that you become 4. the diagnosis including any applicable
familiar with the types of claims that can be diagnosis code(s);
submitted to us and the timeframes and other 5. the Provider's name and address;
requirements that apply.
6. the name of the individual who received the
Service; and
Claims Processing 20-1
7. the Covered Plan Participant's name and claim or a portion of the claim is contested. Our
contract number as they appear on the ID notice may identify: 1)the contested portion or
Card. portions of the claim;2)the reason(s)for
The itemized statement and claim form must be contesting the claim or a portion of the claim;
received by us at the address indicated on your and 3)the date that we reasonably expect to
ID Card. notify you of the decision. The notice may also
indicate whether additional information is
Note: Special claims processing rules may needed in order to complete processing of the
apply for Health Care Services you receive claim. If we request additional information,we
outside the state of Florida under the BlueCardo must receive it within 45 days of our request for
Program (See the"BlueCard`"(Out-of-State) the information. If we do not receive the
Program" section of this Booklet). requested information,the claim or a portion
The Processing of Post-Service Claims of the claim will be adjudicated based on the
information in our possession at the time
We will use our best efforts to pay,contest,or and may be denied. Upon receipt of the
deny all Post-Service Claims for which we have requested information,we will use our best
all of the necessary information, as determined efforts to complete the processing of the Post-
by us. Post-Service Claims will be paid, Service Claim within 15 days of receipt of the
contested, or denied within the timeframes information.
described below. Denial of Post-Service Claims
• Payment for Post-Service Claims In the event we deny a Post-Service Claim
When payment is due under the terms of this submitted electronically,we will use our best
Benefit Booklet,we will use our best efforts to efforts to provide notice,within 20 days of
pay(in whole or in part)for electronically receipt, that the claim or a portion of the claim is
submitted Post-Service Claims within 20 days of denied. In the event we deny a paper Post-
receipt. Likewise, we will use our best efforts to Service Claim, we will use our best efforts to
pay(in whole or in part)for paper Post-Service provide notice, within 30 days of receipt,that the
Claims within 40 days of receipt. You may claim or a portion of the claim is denied. The
receive notice of payment for paper claims notice may identify the denied portion(s)of the
within 30 days of receipt. If we are unable to claim and the reason(s)for denial. It is your
determine whether the claim or a portion of the responsibility to ensure that we receive all
claim is payable because we need more or information determined by us as necessary to
additional Information, we may contest the claim
adjudicate a Post-Service Claim. If we do not
within the timeframes set forth below. receive the necessary information,the claim
or a portion of the claim may be denied.
• Contested Post-Service Claims
A Post-Service Claim denial is an Adverse
In the event we contest an electronically Benefit Determination and is subject to the
submitted Post-Service Claim, or a portion of Adverse Benefit Determination standards and
such a claim,we will use our best efforts to
appeal procedures described in this section.
provide notice,within 20 days of receipt,that the
claim or a portion of the claim is contested. In Additional Processing Information for Post-
the event we contest a Post-Service Claim Service Claims
submitted on a paper claim form, or a portion of In any event,we will use our best efforts to pay
such a claim,we will use our best efforts to or deny all: 1)electronic Post-Service Claims
provide notice, within 30 days of receipt,that the within 90 days of receipt of the completed claim;
I
Claims Processing 20-2
and 2)Post-Service paper claims within 120 Benefit Determinations on Pre-Service Claims
days of receipt of the completed claim. Claims Involving Urgent Care
processing shall be deemed to have been For a Pre-Service Claim Involving Urgent Care,
completed as of the date the notice of the claims decision is deposited in the mail by us or we will use our best efforts to provide notice of
I
otherwise electronically transmitted. Any claims our determination(whether adverse or not)as
soon as possible, but not later than 72 hours
payment relating to aPost-Service Claim that is after receipt of the Pre-Service Claim unless
not made by us within the applicable timeframe
additional information is required for a coverage
Is subject to the payment of simple interest at decision. If additional information is necessary
the rate established by the Florida Insurance
to make a determination, we will use our best
Code. efforts to provide notice within 24 hours of: 1)
We will investigate any allegation of improper the need for additional information; 2)the
billing by a Provider upon receipt of written specific information that you or your Provider
notification from you. If we determine that you may need to provide; and 3)the date that we
were billed for a Service that was not actually reasonably expect to provide notice of the
performed, any payment amount will be adjusted decision. If we request additional information,
and, if applicable, a refund will be requested. In we must receive it within 48 hours of our
such a case, if payment to the Provider is request. We will use our best efforts to provide
reduced due solely to the notification from you, notice of the decision on your Pre-Service Claim
we will pay you 20 percent of the amount of the within 48 hours after the earlier of: 1)receipt of
reduction, up to a total of$500. the requested information; or 2)the end of the
period you were afforded to provide the
Pre-Service Claims specified additional information as described
above.
How to File a Pre-Service Claim
Benefit Determinations on Pre-Service Claims
This Benefit Booklet may condition coverage, that Do Not Involve Urgent Care
benefits, or payment(in whole or in part),for a
specific Covered Service, on the receipt by us of We will use our best efforts to provide notice of a
a Pre-Service Claim as that term is defined decision on a Pre-Service Claim not involving
herein. In order to determine whether we must urgent care within 15 days of receipt provided
receive a Pre-Service Claim for a particular additional information is not required for a
Covered Service, please refer to the"What Is coverage decision. This 15-day determination
Covered?" section and other applicable sections period may be extended by us one time for up to
of this Benefit Booklet. You may also call the an additional 15 days. If such an extension is
customer service number on your ID card for necessary,we will use our best efforts to provide
assistance. notice of the extension and reasons for it. We
will use our best efforts to provide notification of
We are not required to render an opinion or the decision on your Pre-Service claim within a
make a coverage or benefit determination with total of 30 days of the initial receipt of the claim,
respect to a Service that has not actually been if an extension of time was taken by us.
provided to you unless the terms of this Benefit
Booklet require(or condition payment upon) If additional information is necessary to make a
approval by us for the Service before it is determination,we will use our best efforts to:
received. 1)provide notice of the need for additional
information, prior to the expiration of the initial
15-day period;2)identify the specific information
Claims Processing 20-3
that you or your Provider may need to provide; Reauests for Extension of Services
and 3)inform you of the date that we reasonably Your Provider may request an extension of
expect to notify you of our decision. If we coverage or benefits for a Service beyond the
request additional information, we must receive approved period of time or number of approved
it within 45 days of our request for the Services. If the request for an extension is for a
information. We will use our best efforts to Claim Involving Urgent Care, we will use our
provide notification of the decision on your Pre- best efforts to notify you of the approval or denial
Service Claim within 15 days of receipt of the of such requested extension within 24 hours
requested information. after receipt of your request, provided it is
A Pre-Service Claim denial is an Adverse received at least 24 hours prior to the expiration
Benefit Determination and is subject to the of the previously approved number or length of
Adverse Benefit Determination standards and coverage for such Services. We will use our
appeal procedures described in this section. best efforts to notify you within 24 hours if: 1)we
need additional information; or 2)you or your
Concurrent Care Decisions representative failed to follow proper procedures
in your request for an extension. If we request
Reduction or Termination of Coverage or additional information, you will have 48 hours to
Benefits for Services provide the requested information.We may
A reduction or termination of coverage or notify you orally or in writing, unless you or your
benefits for Services will be considered an representative specifically request that it be in
Adverse Benefit Determination when: writing. A denial of a request for extension of
Services is considered an Adverse Benefit
• we have approved in writing coverage or Determination and is subject to the Adverse
benefits for an ongoing course of Services to Benefit Determination review procedure below.
be provided over a period of time or a
number of Services to be rendered; and Standards for Adverse Benefit
Determinations
• the reduction or termination occurs before
the end of such previously approved time or Manner and Content of a Notification of an
number of Services;and Adverse Benefit Determination:
• the reduction or termination of coverage or We will use our best efforts to provide notice of
benefits by us was not due to an any Adverse Benefit Determination in writing.
amendment of this Benefit Booklet or Notification of an Adverse Benefit Determination
termination of your coverage as provided by will include(or will be made available to you free
this Benefit Booklet. of charge upon request):
We will use our best efforts to notify you of such 1. the date the Service or supply was provided;
reduction or termination in advance so that you 2. the Provider's name;
will have a reasonable amount of time to have
the reduction or termination reviewed in 3. the dollar amount of the claim, if applicable;
accordance with the Adverse Benefit 4. the diagnosis codes included on the claim
Determination standards and procedures (e.g., ICD-9, DSM-IV), including a
described below. In no event shall we be description of such codes;
required to provide more than a reasonable
period of time within which you may develop 5. the standardized procedure code included
on the claim (e.g., Current Procedural
your appeal before we actually terminate or Terminology), including a description of such
reduce coverage for the Services. codes;
Claims Processing 20-4
6. the specific reason or reasons for the submitted to us in writing for an internal appeal
Adverse Benefit Determination, including within 365 days of the original Adverse Benefit
any applicable denial code; Determination, except in the case of Concurrent
Care Decisions which may, depending upon the
7. a description of the specific Benefit Booklet circumstances, require you to file within a
provisions upon which the Adverse Benefit shorter period of time from notice of the denial.
Determination is based, as well as any The following guidelines are applicable to
internal rule, guideline, protocol, or other reviews of Adverse Benefit Determinations:
similar criterion that was relied upon in
making the Adverse Benefit Determination; • We must receive your appeal of an Adverse
Benefit Determination in person or in writing;
i3. a description of any additional information
that might change the determination and
• You may request to review pertinent
why that information is necessary; documents, such as any internal rule,
guideline, protocol,or similar criterion relied
9. a description of the Adverse Benefit upon to make the determination,and submit
Determination review procedures and the issues or comments in writing;
time limits applicable to such procedures; • If the Adverse Benefit Determination is
10. if the Adverse Benefit Determination is based on the lack of Medical Necessity of a
based on the Medical Necessity or particular Service or the Experimental or
Experimental or Investigational limitations Investigational exclusion, you may request,
and exclusions, a statement telling you how
free of charge,an explanation of the
scientific or clinical judgment relied upon, if
to obtain the specific explanation of the any,for the determination,that applies the
scientific or clinical judgment for the terms of this Benefit Booklet to your medical
determination; and circumstances;
11. You have the right to an independent • During the review process, the Services in
external review through an external review question will be reviewed without regard to
organization for certain appeals, as provided the decision reached in the initial
in the Patient Protection and Affordable determination;
Care Act of 2010.
• We may consult with appropriate
If the claim is a Claim Involving Urgent Care,we Physicians,as necessary;
may notify you orally within the proper
• Any independent medical consultant who
timeframes, provided we follow-up with a written reviews your Adverse Benefit Determination
or electronic notification meeting the on our behalf will be identified upon request;
requirements of this subsection no later than
three days after the oral notification.
• If your claim is a Claim Involving Urgent
Care, you may request an expedited appeal
How to Appeal an Adverse Benefit orally or in writing in which case all
Determination necessary information on review may be
transmitted between you and us by
Except as described below, only you, or a telephone,facsimile or other available
representative designated by you in writing, expeditious method;and
have the right to appeal an Adverse Benefit 0 If you wish to give someone else permission
Determination. An appeal of an Adverse Benefit to appeal an Adverse Benefit Determination
Determination will be reviewed using the review on your behalf,we must receive a
process described below. Your appeal must be completed Appointment of Representative
Claims Processing 20-5
form signed by you indicating the name of will respond to you, within a reasonable time, not
the person who will represent you with to exceed 15 business days.
respect to the appeal. An Appointment of
Representative form is not required if your Requests for an internal appeal should be
Physician is appealing an Adverse Benefit sent to the address below:
Determination relating to a Claim Involving Blue Cross and Blue Shield of Florida, Inc.
Urgent Care. Appointment of Attention: Member Appeals
Representative forms are available at P.O. Box 44197
www.bcbsfl.com or by calling the number on Jacksonville, Florida 32231-4197
the back of your BCBSF ID Card.
Timinq of Our Aooeal Review on Adverse How to Request External Review of
Benefit Determinations Our Appeal Decision
We will use our best efforts to review your If you are not satisfied with our internal review of
appeal of an Adverse Benefit Determination and your appeal of an Adverse Benefit
communicate the decision in accordance with Determination, please refer to the Adverse
the following time frames: Benefit Determination notice or call the customer
• Pre-Service Claims--within 30 days of the service phone number on your ID Card for
receipt of your appeal; or information on how to request an external
review.
• Post-Service Claims--within 60 days of the
receipt of your appeal;or Additional Claims Processing
• Claims Involving Urgent Care(and requests Provisions
to extend concurrent care Services made
1. Release of Information/Cooperation:
within 24 hours prior to the termination of the
Services)--within 72 hours of receipt of your In order to process claims,we may need
request. If additional information is certain information, including information
necessary we will notify you within 24 hours regarding other health care coverage you
and we must receive the requested may have. You must cooperate with us in
additional information within 48 hours of our our effort to obtain such information by,
request. After we receive the additional among other ways, signing any release of
information,we will have an additional 48 information form at our request. Failure by
hours to make a final determination. you to fully cooperate with us may result in a
Note: The nature of a claim for Services(i.e. denial of the pending claim and we will have
whether it is"urgent care" or not)is judged as of no liability for such claim.
the time of the benefit determination on review, 2. Physical Examination:
not as of the time the Service was initially
In order to make coverage and benefit
reviewed or provided.
decisions,we may, at our expense, require
You,or a Provider acting on your behalf,who you to be examined by a health care
has had a claim denied as not Medically Provider of our choice as often as is
Necessary has the opportunity to appeal the reasonably necessary while a claim is
claim denial.The appeal may be directed to an pending. Failure by you to fully cooperate
employee of BCBSF who is a licensed Physician with such examination shall result in a denial
responsible for Medical Necessity reviews.The of the pending claim and we shall have no
appeal may be by telephone and the Physician liability for such claim.
Claims Processing 20-6
i
3. Legal Actions: d) A description of the applicable Adverse
No legal action arising out of or in Benefit Determination review
connection with coverage under this Benefit procedures and the time limits
Booklet may be brought against us within applicable to such procedures; and
the 60-day period following our receipt of the e) if the Adverse Benefit Determination is
completed claim as required herein. based on the Medical Necessity or
Additionally, no such action may be brought Experimental or Investigational
after expiration of the applicable statute of limitations and exclusions, a statement
limitations. telling you how you can obtain the
4. Fraud,Misrepresentation or Omission in
specific explanation of the scientific or
Applying for Benefits: clinical judgment for the determination.
We rely on the information provided on the 6. Circumstances Beyond Our Control:
itemized statement and the claim form when To the extent that natural disaster,war, riot,
processing a claim. All such information, civil insurrection,epidemic,or other
therefore, must be accurate,truthful and emergency or similar event not within our
complete. Any fraudulent statement, control, results in facilities, personnel or our
omission or concealment of facts, financial resources being unable to process
misrepresentation, or incorrect information claims for Covered Services,we will have no
may result, in addition to any other legal liability or obligation for any delay in the
remedy we may have, in denial of the claim payment of claims for Covered Services,
or cancellation or rescission of your except that we will make a good faith effort
coverage. to make payment for such Services,taking
5. Explanation of Benefits Form: into account the impact of the event. For the
purposes of this paragraph, an event is not
All claims decisions,including denial and
claims review decisions,will be within our control if we cannot effectively
communicated to you in writing either on an exercise influence or dominion over its
explanation of benefits form or some other occurrence or non-occurrence.
written correspondence. This form may
indicate:
a) The specific reason or reasons for the
Adverse Benefit Determination;
b) Reference to the specific Benefit
Booklet provisions upon which the
Adverse Benefit Determination is based
as well as any internal rule, guideline,
protocol, or other similar criterion that
was relied upon in making the Adverse
Benefit Determination;
c) A description of any additional
information that would change the initial
determination and why that information
is necessary;
I
Claims Processing 20.7
Section 21 : Relationship Between the Parties
BCBSF/Monroe County BOCC and nor Monroe County BOCC will be liable, whether
Health Care Providers in tort or contract or otherwise,for any acts or
omissions of any other person or organization
Neither BCBSF nor Monroe County BOCC nor with which BCBSF has made or hereafter makes
any of their officers, directors or employees arrangements for the provision of Covered
provides Health Care Services to you. Rather, Services. BCBSF is not your agent, servant, or
BCBSF and Monroe County BOCC are engaged representative nor is BCBSF an agent, servant,
in making coverage and benefit decisions under or representative of Monroe County BOCC and
this Booklet. By accepting the Group health BCBSF will not be liable for any acts or
care coverage and benefits, you agree that omissions, or those of Monroe County BOCC,its
making such coverage and benefit decisions agents, servants, employees, or any person or
does not constitute the rendering of Health Care organization with which Monroe County BOCC
Services and that health care Providers has entered into any agreement or arrangement.
rendering those Services are not employees or By acceptance of coverage and benefits
agents of BCBSF or Monroe County BOCC. In hereunder, you agree to the foregoing.
this regard,we and Monroe County BOCC
hereby expressly disclaim any agency Medical Treatment Decisions -
relationship, actual or implied,with any Responsibility of Your Physician, Not
health care Provider. BCBSF and Monroe BCBSF
County BOCC do not, by virtue of making
coverage, benefit, and payment decisions, Any and all decisions that require or pertain to
exercise any control or direction over the independent professional medical judgment or
medical judgment or clinical decisions of any training, or the need for medical Services or
health care Provider. Any decisions made under supplies, must be made solely by your family
the Group Health Plan concerning and your treating Physician in accordance with
appropriateness of setting,or whether any the patient/physician relationship. It is possible
Service is Medically Necessary, shall be that you or your treating Physician may conclude
deemed to be made solely for purposes of that a particular procedure is needed,
determining whether such Services are covered, appropriate,or desirable, even though such
and not for purposes of recommending any procedure may not be covered.
treatment or non-treatment. Neither BCBSF nor
Monroe County BOCC will assume liability for
any loss or damage arising as a result of acts or
omissions of any health care Provider.
Non Liability of BCBSF and Monroe
County BOCC
Neither Monroe County BOCC nor any person
covered under this Booklet is BCBSF's agent or
representative, and neither shall be liable for any
acts or omissions by BCBSF's agents, servants,
employees, or us. Additionally, neither BCBSF
Relationship Between the Parties 21_1
Section 22: General Provisions
Access to Information
BCBSF and Monroe County BOCC have the Compliance with State and Federal
right to receive,from you and any health care Laws and Regulations
Provider rendering Services to you, information
that is reasonably necessary,as determined by The terms of coverage and benefits to be
BCBSF and Monroe County BOCC, in order to provided under this Benefit Booklet shall be
administer the coverage and benefits provided, deemed to have been modified and shall be
subject to all applicable confidentiality interpreted, so as to comply with applicable state
requirements listed below. By accepting or federal laws and regulations dealing with
coverage, you authorize every health care benefits, eligibility, enrollment,termination, or
Provider who renders Services to you, to other rights and duties.
disclose to BCBSF and Monroe County BOCC
or to affiliated entities, upon request, all facts, Confidentiality
records, and reports pertaining to your care,
treatment, and physical or mental Condition,and Except as otherwise specifically provided herein,
to permit BCBSF and/or Monroe County BOCC and except as may be required in order for us to
to copy any such records and reports so administer coverage and benefits, specific
obtained. medical information concerning
you, received by
Providers, shall be kept confidential by us in
Right to Receive Necessary conformity with applicable law. Such information
Information may be disclosed to third parties for use in
connection with bona fide medical research and
In order to administer coverage and benefits, education, or as reasonably necessary in
BCBSF or Monroe County BOCC may,without connection with the administration of coverage
the consent of, or notice to, any person, plan, or
organization, obtain from any person, plan, or and benefits, specifically including BCBSF's
quality assurance and Blueprint for Health
organization any information with respect to any
person covered under this Booklet or applicant Programs. Additionally, we may disclose such
for enrollment which BCBSF or Monroe County information to entities affiliated with us or other
BOCC deem to be necessary. persons or entities we utilize to assist in
providing coverage, benefits or services under
Right to Recovery this Booklet. Further, any documents or
information which are properly subpoenaed in a
Whenever the Group Health Plan has made judicial proceeding, or by order of a regulatory
payments in excess of the maximum provided agency, shall not be subject to this provision.
for under this Booklet, BCBSF or Monroe BCBSF's arrangements with a Provider may
County BOCC will have the right to recover any require that we release certain claims and
such payments,to the extent of such excess, medical information about persons covered
from you or any person, plan,or other
organization that received such payments. under this Booklet to that Provider even if
treatment has not been sought by or through
that Provider. By accepting coverage, you
General Provisions 22.E
hereby authorize us to release to Providers Non-Waiver of Defaults
claims information, including related medical
information, pertaining to you in order for any Any failure by BCBSF or Monroe County BOCC
such Provider to evaluate your financial at any time, or from time to time,to enforce or to
responsibility under this Booklet. require the strict adherence to any of the terms
or conditions described herein, will in no event
Benefit Booklet constitute a waiver of any such terms or
conditions. Further, it will not affect BCBSF's or
You have been provided with this Benefit Monroe County BOCC's right at any time to
Booklet and an Identification Card as evidence enforce any terms or conditions under this
of your coverage under this Benefit Booklet.
Benefit Booklet.
Modification of Provider Network and Notices
the Participation Status Any notice required or permitted hereunder will
be deemed given if hand delivered or if mailed
NetworkBlue and the Traditional Provider by United States Mail, postage prepaid, and
Program, and the participation status of addressed as listed below. Such notice will be
individual Providers available through BCBSF, deemed effective as of the date delivered or so
are subject to change at any time by BCBSF deposited in the mail.
without prior notice to you or your approval or If to BCBSF:
that of Monroe County BOCC. Additionally,
BCBSF may, at any time,terminate or modify To the address printed on the Identification
the terms of any Provider contract and may Card.
enter into additional Provider contracts without If to you:
prior notice to you,or your approval or that of
Monroe County BOCC. It is your responsibility To the latest address provided by you or to
to determine whether a health care Provider is your latest address on Enrollment Forms
an In-Network Provider at the time the Health actually delivered to us.
Care Service is rendered. Under this Booklet, You must notify Monroe County BOCC
your financial responsibility may vary depending Benefits Office immediately of any
upon a Provider's participation status. address change.
Cooperation Required of You and If to Monroe County BOCC:
Your Covered Dependents To the address indicated by Monroe County
BOCC.
You must cooperate with BCBSF and Monroe
County BOCC, and must execute and submit to Our Obligations Upon Termination
us any consents, releases, assignments, and Upon termination of your coverage for any
other documents requested in order to reason,there will be no further liability or
administer, and exercise any rights hereunder. responsibility to you under the Group Health
Failure to do so may result in the denial of Plan, except as specifically described herein.
claims and will constitute grounds for termination
for cause(See the Termination of an Individual's Promissory Estoppel
Coverage for Cause subsection in the No oral statements, representations, or
Termination Of Coverage section). understanding by any person can change, alter,
General Provisions 22_2
delete, add,or otherwise modify the express discontinue or modify any reward program
written terms of this Booklet. features or promotional offers at any time
without your consent.
Florida Agency for Health Care
Administration Performance Data
The performance outcome and financial data
published by the Agency for Health Care
Administration (AHCA), pursuant to Florida
Statute 408.05,or any successor statute,
located at the web site address
www.floridahealthfinder.cyov,may be accessed
through the link provided on the Blue Cross and
Blue Shield of Florida corporate web site at
www.bcbsfl.com.
Third Party Beneficiary
The terms and provisions of the Group Health
Plan shall be binding solely upon, and inure
solely to the benefit of, Monroe County BOCC
and individuals covered under the terms of this
Benefit Booklet, and no other person shall have
any rights, interest or claims thereunder, or
under this Benefit Booklet, or be entitled to sue
for a breach thereof as a third-party beneficiary
or otherwise. Monroe County BOCC hereby
specifically expresses its intent that health care
Providers that have not entered into contracts
with BCBSF to participate in BCBSF's Provider
networks shall not be third-party beneficiaries
under the terms of the Monroe County BOCC
Group Health Plan or this Benefit Booklet.
Customer Rewards Programs
From time to time,we may offer programs to our
customers that provide rewards for following the
terms of the program. We will tell you about any
available rewards programs in general mailings,
member newsletters and/or on our website.
Your participation in these programs is
completely voluntary and will in no way affect
the coverage available to you under this Benefit
Booklet. We reserve the right to offer rewards in
excess of$25 per year as well as the right to
General Provisions 22-3
Section 23: Definitions
The following definitions are used in this Benefit 1. In the case of an In-Network Provider
Booklet. Other definitions may be found in the located in Florida,this amount will be
particular section or subsection where they are established in accordance with the
used. applicable agreement between that Provider
Accident means an unintentional, unexpected and BCBSF.
event, other than the acute onset of a bodily 2. In the case of an In-Network Provider
infirmity or disease, which results in traumatic located outside of Florida, this amount will
injury. This term does not include injuries generally be established in accordance with
caused by surgery or treatment for disease or the negotiated price that the on-site Blue
illness. Cross and/or Blue Shield Plan ("Host Blue")
passes on to us,except when the Host Blue
Accidental Dental Injury means an injury to is unable to pass on its negotiated price due
sound natural teeth(not previously to the terms of its Provider contracts. See
compromised by decay)caused by a sudden, the BlueCard®(Out-of-State) Program
unintentional, and unexpected event or force. section for more details.
This term does not include injuries to the mouth, 3. In the case of Out-of-Network Providers
structures within the oral cavity, or injuries to located in Florida who participate in the
natural teeth caused by biting or chewing, Traditional Program,this amount will be
surgery, or treatment for a disease or illness. established in accordance with the
Administrative Services Only Agreement or applicable agreement between that Provider
ASO Agreement means an agreement between and BCBSF.
Monroe County BOCC and BCBSF. Under the 4. In the case of Out-of-Network Providers
Administrative Services Only Agreement, located outside of Florida who participate in
BCBSF provides claims processing and the BlueCard®(Out-of-State)Traditional
payment services, customer service, utilization Program, this amount will generally be
review services and access to BCBSF's established in accordance with the
NetworkBlue and BCBSF's network of negotiated price that the Host Blue passes
Traditional Insurance Providers. on to us, except when the Host Blue is
Adverse Benefit Determination means any unable to pass on its negotiated price due to
denial, reduction or termination of coverage, the terms of its Provider contracts. See the
benefits, or payment(in whole or in part)under BlueCard®(Out-of-State) Program section
the Benefit Booklet with respect to a Pre-Service for more details.
Claim or a Post-Service Claim. Any reduction or 5. In the case of an Out-of-Network Provider
termination of coverage, benefits, or payment in that has not entered into an agreement with
connection with a Concurrent Care Decision, as BCBSF to provide access to a discount from
described in this section, shall also constitute an the billed amount of that Provider for the
Adverse Benefit Determination. specific Covered Services provided to you,
Allowed Amount means the maximum amount the Allowed Amount will be the lesser of that
upon which payment will be based for Covered Provider's actual billed amount for the
Services. The Allowed Amount may be changed specific Covered Services or an amount
at any time without notice to you or your established by BCBSF that may be based
consent. on several factors including (but not
Definitions
23-1
necessarily limited to): (i)payment for such billed by such Out-of-Network Provider for such
Services under the Medicare and/or Services. You will be responsible for any
Medicaid programs; (ii)payment often difference between such Allowed Amount and
accepted for such Services by that Out-of- the amount billed for such Services by any such
Network Provider and/or by other Providers, Out-of-Network Provider.
either in Florida or in other comparable Ambulance means a ground or water vehicle,
market(s),that BCBSF determines are airplane or helicopter properly licensed pursuant
comparable to the Out-of-Network Provider to Chapter 401 of the Florida Statutes,or a
that provided the specific Covered Services similar applicable law in another state.
(which may include payment accepted by Ambulatory Surgical Center means a facility
such Out-of-Network Provider and/or by properly licensed pursuant to Chapter 395 of the
other Providers as participating providers in Florida Statutes,or a similar applicable law of
other provider networks of third-party payers another state,the primary purpose of which is to
which may include,for example,other provide elective surgical care to a patient,
insurance companies and/or health admitted to, and discharged from such facility
maintenance organizations); (iii)payment within the same working day.
amounts which are consistent, as Applied Behavior Analysis means the design,
determined by BCBSF,with BCBSF's implementation and evaluation of environmental
provider network strategies(e.g., does not modifications, using behavioral stimuli and
result in payment that encourages Providers consequences to produce socially significant
participating in a BCBSF network to become improvement in human behavior,including, but
non-participating); and/or, (iv)the cost of not limited to,the use of direct observation,
providing the specific Covered Services. In measurement and functional analysis of the
the case of an Out-of-Network Provider that relations between environment and behavior.
has not entered into an agreement with Artificial Insemination (Al) means a medical
another Blue Cross and/or Blue Shield procedure in which sperm is placed into the
organization to provide access to discounts female reproductive tract by a qualified health
from the billed amount for the specific care provider for the purpose of producing a
Covered Services under the BlueCard (Out- pregnancy.
of-State)Program, the Allowed Amount for Autism Spectrum Disorder means any of the
the specific Covered Services provided to following disorders as defined in the diagnostic
you may be based upon the amount categories of the International Classification of
provided to BCBSF by the other Blue Cross Diseases, Ninth Edition, Clinical Modification
and/or Blue Shield organization where the (ICD-9 CM),or their equivalents in the most
Services were provided at the amount such recently published version of the American
organization would pay non-participating Psychiatric Association's Diagnostic and
Providers in its geographic area for such Statistical Manual of Mental Disorders:
Services. 1. Autistic disorder;
Please specifically note that, in the case of an 2. Asperger's syndrome;
Out-of-Network Provider that has not entered
into an agreement with BCBSF to provide 3. Pervasive developmental disorder not
access to a discount from the billed amount of otherwise specified;and
that Provider, the Allowed Amount for particular 4. Childhood Disintegrative Disorder.
Services is often substantially below the amount
Definitions 23.2
Benefit Period means a consecutive period of BlueCard®(Out-of-State)PPO Program
time, specified by BCBSF and the Group, in Provider means a Provider designated as a
which benefits accumulate toward the BlueCard®(Out-of-State)PPO Program Provider
satisfaction of Deductibles,out-of-pocket by the Host Blue.
maximums and any applicable benefit
BlueCard (Out-of-State)Traditional Program
maximums. Your Benefit Period is listed on your Provider means a Provider designated as a
Schedule of Benefits,and will not be less than BlueCard®(Out-of-State)Traditional Program
12 months unless indicated as such. Provider by the Host Blue.
Birth Center means a facility or institution, other Bone Marrow Transplant means human blood
than a Hospital or Ambulatory Surgical Center, precursor cells administered to a patient to
which is properly licensed pursuant to Chapter restore normal hematological and immunological
383 of the Florida Statutes,or a similar functions following ablative or non-ablative
applicable law of another state, in which births therapy with curative or life-prolonging intent.
are planned to occur away from the mother's Human blood precursor cells may be obtained
usual residence following a normal, from the patient in an autologous transplant, or
uncomplicated, low-risk pregnancy. an allogeneic transplant from a medically
® acceptable related or unrelated donor, and may
BlueCard (Out-of-State) Program means a be derived from bone marrow, the circulating
national Blue Cross and Blue Shield Association blood,or a combination of bone marrow and
program available through Blue Cross and Blue circulating blood. If chemotherapy is an integral
Shield of Florida, Inc. Subject to any applicable part of the treatment involving bone marrow
BlueCard'(Out-of-State) Program rules and transplantation,the term "Bone Marrow
protocols, you may have access to the Provider Transplant"includes the transplantation as well
discounts of other participating Blue Cross and/or as the administration of chemotherapy and the
Blue Shield plans. Seethe BlueCard®(Out-of- chemotherapy drugs. The term "Bone Marrow
State)Program section for more details. Transplant"also includes any Services or
® supplies relating to any treatment or therapy
BlueCard (Out-of-State) PPO Program involving the use of high dose or intensive dose
means a national Blue Cross and Blue Shield chemotherapy and human blood precursor cells
Association program available through Blue and includes any and all Hospital, Physician or
Cross and Blue Shield of Florida, Inc. Subject to other health care Provider Health Care Services
any applicable BlueCard®(Out-of-State) which are rendered in order to treat the effects
Program rules and protocols,you may have of, or complications arising from, the use of high
access to the BlueCard®(Out-of-State) PPO dose or intensive dose chemotherapy or human
Program discounts of other participating Blue blood precursor cells(e.g., Hospital room and
Cross and/or Blue Shield plans. board and ancillary Services).
BlueCard®(Out-of-State)Traditional Program Calendar Year begins January 1st and ends
means a national Blue Cross and Blue Shield December 31st.
Association program available through Blue Cardiac Therapy means Health Care Services
Cross and Blue Shield of Florida, Inc. Subject to provided under the supervision of a Physician,
any applicable BlueCard (Out-of-State) or an appropriate Provider trained for Cardiac
Program rules and protocols, you may have Therapy,for the purpose of aiding in the
access to the BlueCard®(Out-of-State) restoration of normal heart function in
Traditional Program discounts of other connection with a myocardial infarction,
participating Blue Cross and/or Blue Shield coronary occlusion or coronary bypass surgery.
plans.
Defindions 23-3
Certified Nurse Midwife means a person who or terminate coverage, benefits,or payment
is licensed pursuant to Chapter 464 of the under the personal case management Program
Florida Statutes, or a similar applicable law of as described in the"Blueprint For Health
another state, as an advanced nurse practitioner Programs" section of this Benefit Booklet.
and who is certified to practice midwifery by the
American College of Nurse Midwives. Condition means a disease, illness, ailment,
injury, or pregnancy.
Certified Registered Nurse Anesthetist
means a person who is a properly licensed Convenient Care Center means a properly
nurse who is a certified advanced registered
licensed ambulatory center that: 1)treats a
nurse practitioner within the nurse anesthetist limited number of common, low-intensity
category pursuant to Chapter 464 of the Florida illnesses when ready access to the patient's
Statutes, or a similar applicable law of another primary physician is not possible; 2)shares
state. clinical information about the treatment with the
patient's primary physician; 3) is usually housed
Claim Involving Urgent Care means any in a retail business; and 4)is staffed by at least
request or application for coverage or benefits one master's level nurse(ARNP)who operates
for medical care or treatment that has not yet under a set of clinical protocols that strictly
been provided to you with respect to which the circumscribe the conditions the ARNP can treat.
application of time periods for making non- Although no physician is present at the
urgent care benefit determinations: (1)could Convenient Care Center, medical oversight is
seriously jeopardize your life or health or your based on a written collaborative agreement
ability to regain maximum function; or(2)in the between a supervising physician and the ARNP.
opinion of a Physician with knowledge of your
Condition,would subject you to severe pain that Copayment means the dollar amount
cannot be adequately managed without the established solely by BCBSF and Monroe
proposed Services being rendered. County BOCC which is required to be paid to a
health care Provider by you at the time certain
Coinsurance means your share of health care Covered Services are rendered by that Provider.
expenses for Covered Services. After your
Deductible requirement is met, a percentage of Cost Share means the dollar or percentage
the Allowed Amount will be paid for Covered amount established solely by us,which must be
Services, as listed in the Schedule of Benefits. paid to a health care Provider by you at the time
The percentage you are responsible for is your Covered Services are rendered by that Provider.
Coinsurance. Cost Share may include, but is not limited to
Coinsurance, Copayment, Deductible and/or Per
Concurrent Care Decision means a decision Admission Deductible(PAD)amounts.
by us to deny, reduce, or terminate coverage, Applicable Cost Share amounts are identified in
benefits, or payment(in whole or in part)with your Schedule of Benefits.
respect to a course of treatment to be provided
over a period of time, or a specific number of Covered Dependent means an Eligible
treatments, if we had previously approved or Dependent who meets and continues to meet all
authorized in writing coverage, benefits, or applicable eligibility requirements and who is
payment for that course of treatment or number enrolled, and actually covered, under the Group
Health Plan other than as a Covered Plan
of treatments.
Participant(See the"Eligibility Requirements for
As defined herein, a Concurrent Care Decision Dependent(s)"subsection of the"Eligibility for
shall not include any decision to deny, reduce, Coverage" section).
Definitions 23_4
Covered Person means a Covered Plan determined by a licensed Physician or
Participant or a Covered Dependent. Psychologist, while keeping the physiological
Covered Plan Participant means an Eligible risk to the individual at a minimum.
Employee or other individual who meets and Diabetes Educator means a person who is
continues to meet all applicable eligibility properly certified pursuant to Florida law, or a
requirements and who is enrolled, and actually similar applicable law of another state,to
covered, under this Benefit Booklet other than supervise diabetes outpatient self-management
as a Covered Dependent. training and educational services.
Covered Services means those Health Care Dialysis Center means an outpatient facility
Services which meet the criteria listed in the certified by the Centers for Medicare and
"What Is Covered?"section. Medicaid Services (CMMS)and the Florida
Agency for Health Care Administration (or a
Custodial or Custodial Care means care that similar regulatory agency of another state)to
serves to assist an individual in the activities of provide hemodialysis and peritoneal dialysis
daily living, such as assistance in walking, services and support.
getting in and out of bed, bathing,dressing,
feeding, and using the toilet, preparation of Dietitian means a person who is properly
special diets,and supervision of medication that licensed pursuant to Florida law or a similar
usually can be self-administered. Custodial applicable law of another state to provide
Care essentially is personal care that does not nutrition counseling for diabetes outpatient self-
require the continuing attention of trained management services.
medical or paramedical personnel. In
determining whether a person is receiving Durable Medical Equipment means equipment
Custodial Care, consideration is given to the furnished by a supplier or a Home Health
frequency, intensity and level of care and Agency that: 1)can withstand repeated use;
medical supervision required and furnished. A 2)is primarily and customarily used to serve a
determination that care received is Custodial is medical purpose;3)not for comfort or
not based on the patient's diagnosis,type of convenience; 4)generally is not useful to an
Condition, degree of functional limitation, or individual in the absence of a Condition; and
rehabilitation potential. 5) is appropriate for use in the home.
Deductible means the amount of charges, up to Durable Medical Equipment Provider means a
the Allowed Amount, for Covered Services that person or entity that is properly licensed, if
are your responsibility. The term, Deductible, applicable, under Florida law(or a similar
does not include any amounts you are applicable law of another state)to provide home
responsible for in excess of the Allowed Amount, medical equipment, oxygen therapy services, or
or any CoinsurancelCopay amounts, if dialysis supplies in the patient's home under a
applicable. Physician's prescription.
Detoxification means a process whereby an Effective Date means,with respect to
alcohol or drug intoxicated, or alcohol or drug individuals covered under this Benefit Booklet,
dependent, individual is assisted through the 12:01 a.m. on the date Monroe County BOCC
period of time necessary to eliminate, by specifies that the coverage will commence as
metabolic or other means, the intoxicating further described in the "Enrollment and
alcohol or drug, alcohol or drug dependent Effective Date of Coverage" section of this
factors or alcohol in combination with drugs as Benefit Booklet.
Definitions 23-5
Eligible Dependent means an individual who Endorsement means an amendment to the
meets and continues to meet all of the eligibility Group Health Plan or this Booklet.
requirements described in the Eligibility
Requirements for Dependent(s)subsection of Enrollment Date means the date of enrollment
the Eligibility for Coverage section in this Benefit of the individual under the Group Health Plan or,
Booklet, and is eligible to enroll as a Covered if earlier,the first day of the Waiting Period of
Dependent. such enrollment.
Eligible Employee means an active employee Enrollment Forms means those forms,
or retiree who meets and continues to meet all electronic(where available)or paper, which are
of the eligibility requirements described in the used to maintain accurate enrollment files under
Eligibility Requirements for Covered Plan this Benefit Booklet.
Participant subsection of the Eligibility for
Coverage section in the Benefit Booklet and is Experimental or Investigational means any
eligible to enroll as a Covered Plan Participant. evaluation,treatment, therapy, or device which
Any individual who is an Eligible Employee is not involves the application,administration or use, of
a Covered Plan Participant until such individual procedures,techniques,equipment, supplies,
has actually enrolled with, and been accepted products, remedies, vaccines, biological
for coverage as a Covered Plan Participant by products,drugs, pharmaceuticals, or chemical
Monroe County BOCC. compounds if, as determined solely by BCBSF:
Emergency Medical Condition means a 1. such evaluation, treatment, therapy, or
medical or psychiatric Condition or an injury device cannot be lawfully marketed without
manifesting itself by acute symptoms of approval of the United States Food and
sufficient severity(including severe pain)such Drug Administration or the Florida
that a prudent layperson, who possesses an Department of Health and approval for
average knowledge of health and medicine, marketing has not,in fact, been given at the
could reasonably expect the absence of time such is furnished to you; or
immediate medical attention to result in a
condition described in clause(i), (ii), or(iii)of 2• such evaluation,treatment,therapy, or
Section 1867(e)(1)(A)of the Social Security Act. device is provided pursuant to a written
protocol which describes as among its
Emergency Services means,with respect to an objectives the following: determinations of
Emergency Medical Condition: safety, efficacy, or efficacy in comparison to
1. a medical screening examination (as the standard evaluation,treatment,therapy,
required under Section 1867 of the Social or device; or
Security Act)that is within the capability of 3. such evaluation, treatment, therapy, or
the emergency department of a Hospital, device is delivered or should be delivered
including ancillary Services routinely subject to the approval and supervision of
available to the emergency department to an institutional review board or other entity
evaluate such Emergency Medical as required and defined by federal
Condition; and
regulations; or
2. within the capabilities of the staff and
facilities available at the hospital, such 4• credible scientific evidence shows that such
further medical examination and treatment evaluation,treatment,therapy, or device is
as are required under Section 1867 of such the subject of an ongoing Phase I or II
Act to Stabilize the patient. clinical investigation, or the experimental or
research arm of a Phase III clinical
Definitions 23.6
investigation, or under stud to determine:
9 Y 3. published reports, articles, or other literature
maximum tolerated dosage(s),toxicity, of the United States Department of Health
i
safety, efficacy, or efficacy as compared and Human Services or the United States
with the standard means for treatment or Public Health Service, including any of the
diagnosis of the Condition in question; or National Institutes of Health, or the United
5. credible scientific evidence shows that the States Office of Technology Assessment;
consensus of opinion among experts is that 4. the written protocol or protocols relied upon
further studies, research,or clinical by the treating Physician or institution or the
investigations are necessary to determine: protocols of another Physician or institution
maximum tolerated dosage(s),toxicity, studying substantially the same evaluation,
safety, efficacy, or efficacy as compared treatment,therapy, or device;
with the standard means for treatment or 5. the written informed consent used by the
diagnosis of the Condition in question; or treating Physician or institution or by another
6* credible scientific evidence shows that such Physician or institution studying substantially
evaluation,treatment, therapy, or device has the same evaluation,treatment, therapy, or
not been proven safe and effective for device; or
treatment of the Condition in question,as 6. the records(including any reports)of any
evidenced in the most recently published institutional review board of any institution
Medical Literature in the United States, which has reviewed the evaluation,
Canada, or Great Britain, using generally treatment, therapy,
accepted scientific, medical, or public health or device for the
Condition in question.
methodologies or statistical practices;or
Note: Health Care Services which are
7. there is no consensus among practicing determined by BCBSF to be Experimental or
Physicians that the treatment,therapy,or Investigational are excluded (see the"What
device is safe and effective for the Condition Is Not Covered?"section). In determining
in question; or whether a Health Care Service is
8. such evaluation, treatment, therapy, or Experimental or Investigational, BCBSF may
device is not the standard treatment, also rely on the predominant opinion among
therapy, or device utilized by practicing experts, as expressed in the published
Physicians in treating other patients with the authoritative literature,that usage of a
same or similar Condition, particular evaluation,treatment,therapy, or
"Credible scientific evidence"shall mean (as device should be substantially confined to
determined by BCBSF): research settings or that further studies are
necessary In order to define safety,toxicity,
1. records maintained by Physicians or effectiveness,or effectiveness compared
Hospitals rendering care or treatment to you with standard alternatives.
or other patients with the same or similar
Condition; FDA means the United States Food and Drug
2. reports,articles, or written assessments in Administration.
authoritative medical and scientific literature Foster Child means a person who is placed in
published in the United States, Canada,or your residence and care under the Foster Care
Great Britain; Program by the Florida Department of Health &
Rehabilitative Services in compliance with
Florida Statutes or by a similar regulatory
Definrhons 23_7
agency of another state in compliance with that pharmaceuticals,chemical compounds, and
state's applicable laws. other services rendered or supplied, by or at the
Gamete Intrafallopian Transfer(GIFT)means direction of, Providers.
the direct transfer of a mixture of sperm and Home Health Agency means a properly
eggs into the fallopian tube by a qualified health licensed agency or organization which provides
care provider. Fertilization takes place inside health services in the home pursuant to Chapter
the tube. 400 of the Florida Statutes,or a similar
applicable law of another state.
Generally Accepted Standards of Medical
Practice means standards that are based on Home Health Care or Home Health Care
credible scientific evidence published in peer- Services means Physician-directed
reviewed medical literature generally recognized professional,technical and related medical and
by the relevant medical community, Physician personal care Services provided on an
Specialty Society recommendations, and the intermittent or part-time basis directly by(or
views of Physicians practicing in relevant clinical indirectly through)a Home Health Agency in
areas and any other relevant factors. your home or residence. For purposes of this
Gestational Surrogate means a woman, definition, a Hospital, Skilled Nursing Facility,
nursing home or other facility will not be
regardless of age,who contracts,orally or in
considered an individual's home or residence.
writing,to become pregnant by means of
assisted reproductive technology without the use Hospice means a public agency or private
of an egg from her body. organization which is duly licensed by the State
Gestational Surrogacy Contract or of Florida under applicable law, or a similar
Arrangement means an oral or written applicable law of another state, to provide
agreement, regardless of the state or jurisdiction hospice services. In addition, such licensed
where executed, between the Gestational entity must be principally engaged in providing
Surrogate and the intended parent or parents. pain relief,symptom management, and
supportive services to terminally ill persons and
Group means the employer, labor union,trust, their families.
association, partnership,or corporation,
department,other organization or entity through Hospital means a facility properly licensed
which coverage and benefits under this Benefit Pursuant to Chapter 395 of the Florida Statutes,
Booklet are made available to you, and through or a similar applicable law of another state, that:
which you and your Covered Dependents offers services which are more intensive than
become entitled to coverage and benefits for the those required for room, board, personal
� Covered Services described herein. services and general nursing care;offers
facilities and beds for use beyond 24 hours; and
Group Health Plan or Group Plan means the regularly makes available at least clinical
plan established and maintained by Monroe laboratory services, diagnostic x-ray services
County BOCC for the provision of health care and treatment facilities for surgery or obstetrical
coverage and benefits to the individuals covered care or other definitive medical treatment of
under this Benefit Booklet. similar extent.
Health Care Services or Services includes The term Hospital does not include: an
treatments,therapies,devices,procedures, Ambulatory Surgical Center; a Skilled Nursing
techniques, equipment, supplies, products, Facility;a stand-alone Birthing Center;a
remedies,vaccines, biological products,drugs, Psychiatric Facility; a Substance Abuse Facility;
Definitions 23-8
i
a convalescent, rest or nursing home;or a appropriately registered with the Agency for
facility which primarily provides Custodial, Health Care Administration and must comply
educational,or Rehabilitative Therapies. with all applicable Florida law or laws of the
State in which it operates. Further, such an
Note: If services specifically for the entity must meet BCBSF's criteria for eligibility
treatment of a physical disability are as an Independent Diagnostic Testing Facility.
provided in a licensed Hospital which is
accredited by the Joint Commission on the In-Network means,when used in reference to
Accreditation of Health Care Organizations, Covered Services,the level of benefits payable
the American Osteopathic Association,or to an In-Network Provider as designated on the
the Commission on the Accreditation of Schedule of Benefits under the heading "In-
Rehabilitative Facilities, payment for these Network". Otherwise, In-Network means,when
services will not be denied solely because used in reference to a Provider, that,at the time
such Hospital lacks major surgical facilities Covered Services are rendered,the Provider is
an In-Network Provider under the terms of this
and is primarily of a rehabilitative nature. Booklet.
Recognition of these facilities does not
expand the scope of Covered Services. It In-Network Provider means any health care
only expands the setting where Covered Provider who, at the time Covered Services
Services can be performed for coverage were rendered to you, was under contract with
purposes. BCBSF to participate in BCBSF's NetworkBlue
i
and included in the panel of providers
Identification(ID)Card means the card(s) designated by BCBSF as"In-Network"for your
issued to Covered Plan Participants under the specific plan. (Please refer to your Schedule of
BlueOptions Group Health Plan. The card is not Benefits). For payment purposes under this
transferable to another person. Possession of Benefit Booklet only,the term In-Network
such card in no way guarantees that a particular Provider also refers,when applicable, to any
individual is eligible for, or covered under, this health care Provider located outside the state of
Benefit Booklet. Florida who or which, at the time Health Care
Independent Clinical Laboratory means a Services were rendered to you, participated as a
BlueCard (Out-of-State) PPO Program Provider
laboratory properly licensed pursuant to Chapter under the Blue Cross Blue Shield Association's
483 of the Florida Statutes, or a similar BlueCard®(Out-of-State) Program.
applicable law of another state,where
examinations are performed on materials or In Vitro Fertilization (IVF)means a process in
specimens taken from the human body to which an egg and sperm are combined in a
provide information or materials used in the laboratory dish to facilitate fertilization. If
diagnosis, prevention, or treatment of a fertilized,the resulting embryo is transferred to
Condition. the woman's uterus.
Independent Diagnostic Testing Facility Licensed Practical Nurse means a person
means a facility, independent of a Hospital or properly licensed to practice practical nursing
Physician's office,which is a fixed location, a pursuant to Chapter 464 of the Florida Statues,
mobile entity, or an individual non-Physician or a similar applicable law of another state.
practitioner where diagnostic tests are Massage Therapist means a person properly
performed by a licensed Physician or by licensed to practice Massage, pursuant to
licensed, certified non-Physician personnel Chapter 480 of the Florida Statutes,or a similar
under appropriate Physician supervision. An applicable law of another state.
Independent Diagnostic Testing Facility must be
Definitions
23-9 i
I`
Massage or Massage Therapy means the Note: It is important to remember that any
manipulation of superficial tissues of the human review of Medical Necessity by us is solely for
body using the hand,foot, arm, or elbow. For the purpose of determining coverage or benefits
purposes of this Benefit Booklet,the term under this Booklet and not for the purpose of
Massage or Massage Therapy does not include recommending or providing medical care. In this
the application or use of the following or similar respect,we may review specific medical facts or
techniques or items for the purpose of aiding in information pertaining to you. Any such review,
the manipulation of superficial tissues: hot or however, is strictly for the purpose of
cold packs; hydrotherapy; colonic irrigation; determining, among other things, whether a
thermal therapy; chemical or herbal Service provided or proposed meets the
preparations; paraffin baths; infrared light; definition of Medical Necessity in this Booklet as
ultraviolet light; Hubbard tank; or contrast baths. determined by us. In applying the definition of
Medical Necessity in this Booklet, we may apply
Mastectomy means the removal of all or part of the breast for Medically Necessary reasons as our coverage and payment guidelines then ineffect. You are free to obtain a Service even if
determined by a Physician. we deny coverage because the Service is not
Medical literature means scientific studies Medically Necessary; however, you will be solely
published in a United States peer-reviewed responsible for paying for the Service.
national professional journal.
Medicare means the federal health insurance
Medical Pharmacy means Physician- provided under Title XVIII of the Social Security
administered Prescription Drugs which are Act and all amendments thereto.
rendered in a Physician's office
Medication Guide for the purpose of this
Medically Necessary or Medical Necessity Benefit Booklet means the guide then in effect
means that,with respect to a Health Care issued by us where you may find information
Service, a Physician, exercising prudent clinical about Specialty Drugs, Prescription Drugs that
judgment, provided the Health Care Service to require prior coverage authorization and Self-
you for the purpose of preventing, evaluating, Administered Prescription Drugs that may be
diagnosing or treating an illness, injury, disease covered under this plan.
or its symptoms, and that the Health Care
Note: The Medication Guide is subject to
Service was:
change at any time. Please refer to our website
1. in accordance with Generally Accepted at www.bcbsfl.com for the most current guide or
Standards of Medical Practice; you may call the customer service phone
2. clinically appropriate, in terms of type, number on your Identification Card for current
frequency, extent, site and duration, and information.
considered effective for your illness, injury or Mental Health Professional means a person
disease; and properly licensed to provide mental health
3. not primarily for your convenience,or that of Services, pursuant to Chapter 491 of the Florida
your Physician or other health care Provider, Statutes, or a similar applicable law of another
and not more costly than an alternative state. This professional may be a clinical social
Service or sequence of Services at least as worker,mental health counselor or marriage and
likely to produce equivalent therapeutic or family therapist. A Mental Health Professional
diagnostic results as to the diagnosis or does not include members of any religious
treatment of your illness. denomination who provide counseling services.
Definmons 23-10
J
Mental and Nervous Disorder means any Out-of-Network Provider means a Provider
disorder listed in the diagnostic categories of the who, at the time Health Care Services were
International Classification of Diseases, Ninth rendered:
Edition, Clinical Modification(ICD-9 CM), or their 1. did not have a contract with us to participate
equivalents in the most recently published in NetworkBlue but was participating in our
version of the American Psychiatric Traditional Program;or
Association's Diagnostic and Statistical Manual 2. did not have a contract with a Host Blue to
of Mental Disorders, regardless of the underlying participate in its local PPO Program for
cause,or effect, of the disorder. purposes of the BlueCard®(Out-of-State)
Midwife means a person properly licensed to PPO Program but was participating, for
practice midwifery pursuant to Chapter 467 of purposes of the BlueCard®(Out-of-State)
the Florida Statutes, or a similar applicable law Program, as a BlueCard®(Out-of-State)
of another state. Traditional Program Provider;or
NetworkBlue means, or refers to,the preferred 3. did have a contract to participate in
provider network established and so designated NetworkBlue but was not included in the
by BCBSF which is available to individuals panel of Providers designated by us to be
covered under this Benefit Booklet. Please note In-Network for your Plan; or
that BCBSF's Preferred Patient Care(PPC) 4. did not have a contract with us to participate
preferred provider network is not available to in NetworkBlue or our Traditional Program;
individuals covered under this Benefit Booklet. or
Occupational Therapist means a person
5. did not have a contract with a Host Blue to properly licensed to practice Occupational participate for purposes of the BlueCard®
Therapy pursuant to Chapter 468 of the Florida (Out-of-State)Program as a BlueCard®
Statutes,or a similar applicable law of another (Out-of State)Traditional Program Provider.
state. Outpatient Rehabilitation Facility means an
entity which renders,through providers properly
Occupational Therapy means a treatment that
follows an illness or injury and is designed to licensed pursuant to Florida law or the similar
help a patient learn to use a newly restored or
law or laws of another state: outpatient physical
previously impaired function. therapy; outpatient speech therapy; outpatient
occupational therapy; outpatient cardiac
Orthotic Device means any rigid or semi-rigid rehabilitation therapy; and outpatient Massage
device needed to support a weak or deformed for the primary purpose of restoring or improving
body part or restrict or eliminate body a bodily function impaired or eliminated by a
movement. Condition. Further, such an entity must meet
BCBSF's criteria for eligibility as an Outpatient
Out-of-Network means,when used in reference Rehabilitation Facility. The term Outpatient
to Covered Services,the level of benefits Rehabilitation Facility, as used herein, shall not
payable to an Out-of-Network Provider as include any Hospital including a general acute
designated on the Schedule of Benefits under care Hospital, or any separately organized unit
the heading "Out-of-Network". Otherwise, Out- of a Hospital, which provides comprehensive
of-Network means, when used in reference to a medical rehabilitation inpatient services,or
Provider, that, at the time Covered Services are rehabilitation outpatient services, including, but
rendered, the Provider is not an In-Network not limited to,a Class III "specialty rehabilitation
Provider under the terms of this Booklet. hospital"described in Chapter 59A, Florida
Definitions 23_11
Administrative Code or the similar law or laws of diplomates certified by a board recognized by
another state. the American Board of Medical Specialties.
Pain Management includes, but is not limited Post-Service Claim means any paper or
to,Services for pain assessment, medication, electronic request or application for coverage,
physical therapy, biofeedback, and/or benefits, or payment for a Service actually
counseling. Pain rehabilitation programs are provided to you (not just proposed or
programs featuring multidisciplinary Services recommended)that is received by us on a
directed toward helping those with chronic pain properly completed claim form or electronic
to reduce or limit their pain. format acceptable to us in accordance with the
Partial Hospitalization means treatment in provisions of this section.
which an individual receives at least seven Pre-Service Claim means any request or
hours of institutional care during a portion of a application for coverage or benefits for a Service
24-hour period and returns home or leaves the that has not yet been provided to you and with
treatment facility during any period in which respect to which the terms of the Benefit Booklet
treatment is not scheduled. A Hospital shall not condition payment for the Service(in whole or in
be considered a"home"for purposes of this part)on approval by us of coverage or benefits
definition, for the Service before you receive it. A Pre-
Physical Therapy means the treatment of Service Claim may be a Claim Involving Urgent
Care. As defined herein, a Pre-Service Claim
disease or injury by physical or mechanical shall not include a request for a decision or
means as defined in Chapter 486 of the Florida opinion by us regarding coverage, benefits, or
Statutes or a similar applicable law of another payment for a Service that has not actually been
state. Such therapy may include traction,active rendered to you if the terms of the Benefit
or passive exercises, or heat therapy. Booklet do not require(or condition payment
Physical Therapist means a person properly upon)approval by us of coverage or benefits for
licensed to practice Physical Therapy pursuant the Service before it is received.
to Chapter 486 of the Florida Statutes, or a Prescription Drug means any medicinal
similar applicable law of another state. substance, remedy,vaccine, biological product,
Physician means any individual who is properly drug,pharmaceutical or chemical compound
licensed by the state of Florida, or a similar which can only be dispensed with a Prescription
applicable law of another state, as a Doctor of and/or which is required by state law to bear the
Medicine(M.D.), Doctor of Osteopathy(D.O.), following statement or similar statement on the
Doctor of Podiatry(D.P.M.), Doctor of label: "Caution: Federal law prohibits
Chiropractic(D.C.), Doctor of Dental Surgery or dispensing without a Prescription".
Dental Medicine(D.D.S. or D.M.D.), or Doctor of Prior/Concurrent Coverage Affidavit means
Optometry(O.D.). the form that an Eligible Employee or Eligible
Physician Assistant means a person properly Dependent can submit to BCBSF as proof of the
licensed pursuant to Chapter 458 of the Florida amount of time the Eligible Employee was
Statutes,or a similar applicable law of another covered under Creditable Coverage.
state. ProsthetisUOrthotist means a person or entity
Physician Specialty Society means a United that is properly licensed, if applicable, under
States medical specialty society that represents Florida law, or a similar applicable law of
another state,to provide services consisting of
Definitions
23-12
the design and fabrication of medical devices eliminated by a Condition, and include, but are
such as braces, splints, and artificial limbs not limited to, Physical Therapy, Speech
prescribed by a Physician. Therapy, Pain Management, pulmonary therapy
Prosthetic Device means a device which or Cardiac Therapy.
replaces all or part of a body part or an internal Self-Administered Prescription Drug means
body organ or replaces all or part of the an FDA-approved Prescription Drug that you
functions of a permanently inoperative or may administer to yourself, as recommended by
malfunctioning body part or organ. a Physician.
Provider means any facility, person or entity Skilled Nursing Facility means an institution or
recognized for payment by BCBSF under this part thereof which meets BCBSF's criteria for
Booklet. eligibility as a Skilled Nursing Facility and which:
1)is licensed as a Skilled Nursing Facility by the
Psychiatric Facility means a facility properly state of Florida or a similar applicable law of
licensed under Florida law, or a similar another state;and 2)is accredited as a Skilled
applicable law of another state,to provide for the Nursing Facility by the Joint Commission on
care and treatment of Mental and Nervous Accreditation of Healthcare Organizations or
Disorders. For purposes of this Booklet, a recognized as a Skilled Nursing Facility by the
Psychiatric Facility is not a Hospital or a Secretary of Health and Human Services of the
Substance Abuse Facility, as defined herein. United States under Medicare, unless such
accreditation or recognition requirement has
Psychologist means a person properly licensed been waived by BCBSF.
to practice psychology pursuant to Chapter 490
of the Florida Statutes,or a similar applicable Sound Natural Teeth means teeth that are
law of another state. whole or properly restored(restoration with
amalgams, resin or composite only); are without
Registered Nurse means a person properly impairment, periodontal, or other conditions; and
licensed to practice professional nursing are not in need of Services provided for any
pursuant to Chapter 464 of the Florida Statutes, reason other than an Accidental Dental Injury.
or a similar applicable law of another state. Teeth previously restored with a crown, inlay,
onlay,or porcelain restoration, or treated with
Registered Nurse First Assistant(RNFA) endodontics, are not Sound Natural Teeth.
means a person properly licensed to perform
surgical first assisting services pursuant to Specialty Drug means an FDA-approved
Chapter 464 of the Florida Statutes or a similar Prescription Drug that has been designated,
applicable law of another state. solely by us, as a Specialty Drug due to special
handling, storage, training, distribution
Rehabilitation Services means Services for the requirements and/or management of therapy,
purpose of restoring function lost due to illness, Specialty Drugs may be Provider administered
injury or surgical procedures including but not or self-administered and are identified with a
limited to cardiac rehabilitation, pulmonary special symbol in the Medication Guide.
rehabilitation, Occupational Therapy, Speech Specialty Pharmacy means a Pharmacy that
Therapy, Physical Therapy and Massage has signed a Participating Pharmacy Provider
Therapy.
Agreement with us to provide specific
Rehabilitative Therapies means therapies the Prescription Drug products, as determined by
primary purpose of which is to restore or us. In-Network Specialty Pharmacies are listed
improve bodily or mental functions impaired or in the Medication Guide.
Definitions 23_1 g
Speech Therapy means the treatment of Traditional Program Providers means,or
speech and language disorders by a Speech refers to,those health care Providers who are
Therapist including language assessment and not NetworkBlue Providers, but who, or which, at
language restorative therapy services. the time you received Services from them were
Stabilize shall have the same meaning with participating in the Traditional Program. For
regard to Emergency Services as the term is purposes of payment under this Benefit Booklet
defined in Section 1867 of the Social Security only,the term Traditional Program Provider also
Act. refers,when applicable, to any health care
Provider located outside the state of Florida who
Speech Therapist means a person properly or which, at the time Health Care Services were
licensed to practice Speech Therapy pursuant to rendered to you, participated as a BlueCard®
Chapter 468 of the Florida Statutes,or a similar Traditional Provider under the Blue Cross and
applicable law of another state. Blue Shield Association's BlueCard®Program.
Traditional providers are considered out of
Standard Reference Compendium means: network for benefit calculation purposes;
1)the United States Pharmacopoeia Drug however, does not balance bill the member.
Information; 2)the American Medical
Association Drug Evaluation;or 3)the American Urgent Care Center means a facility properly
Hospital Formulary Service Hospital Drug licensed that: 1)is available to provide Services
Information. to patients at least 60 hours per week with at
Substance Abuse Facility means a facility least twenty-five(25)of those available hours
properly licensed under Florida law, or a similar after 5:00 p.m. on weekdays or on Saturday or
Sunday;2) posts instructions for individuals
applicable law of another state,to provide necessary care and treatment for Substance seeking Health Care Services, in a conspicuous Dependency. For the purposes of this Booklet a public place, as to where to obtain such
Services when the Urgent Care Center is
Substance Abuse Facility is not a Hospital or a closed; 3)employs or contracts with at least one
Psychiatric Facility, as defined herein. or more Board Certified or Board Eligible
Substance Dependency means a Condition Physicians and Registered Nurses(RNs)who
where a person's alcohol or drug use injures his are physically present during all hours of
or her health; interferes with his or her social or operation. Physicians, RNs, and other medical
economic functioning; or causes the individual to professional staff must have appropriate training
lose self-control. and skills for the care of adults and children; and
4)maintains and operates basic diagnostic
Traditional Program means, or refers to, radiology and laboratory equipment in
BCBSF's provider contracting programs called compliance with applicable state and/or federal
Payment for Physician Services (PPS)and laws and regulations.
Payment for Hospital Services(PHS). For
purposes of this Benefit Booklet,the term For purposes of this Benefit Booklet, an Urgent
Traditional Program also refers, when Care Center is not a Hospital, Psychiatric
applicable, to the traditional Provider contracting Facility, Substance Abuse Facility, Skilled
programs of other Blue Cross and/or Blue Shield Nursing Facility or Outpatient Rehabilitation
organizations as designated under the Blue Facility.
Cross and Blue Shield Association's BlueCard® Waiting Period means the length of time
Program. established by Monroe County BOCC which
must be met by an individual before that
Definitions
23-14
individual becomes eligible for coverage under
this Benefit Booklet.
Zygote Intrafalloplan Transfer(ZIFT)means a
process in which an egg is fertilized in the
laboratory and the resulting zygote is transferred
to the fallopian tube at the pronuclear stage
(before cell division takes place). The eggs are
retrieved and fertilized on one day and the
zygote is transferred the following day.
Definitions
23-15
Qualified Medical Child Support Orders Disclaimer
Qualified Medical Child Support Orders- The Plan will provide benefits as required by any
Qualified Medical Child Support Order (MCSO). A MCSO can be either:1) A Qualified Medical Child
Support Order (MCSO) that satisfies the requirements of Section 609(a) of ERISA;or 2) A National
Medical Support Notice(NMSN)that satisfies the requirements of Section 1908 of the Social Security Act.
Upon receipt of a MCSO or NMSN by a Covered Employee/Retiree notification must be given to the
Monroe County Group Health Plan Administrator(Benefits Office)within 31 days of receipt. The Covered
Employee/Retiree will need to provide any reasonable information or assistance to the Monroe County
Group Health Plan Administrator
(Benefits Office) in connection with the MCSO.
Disclaimer
t