3rd Amendment 01/19/2011Monroe County Board of County Commissioners
Group Health Plan Document
Amendment #3
WHEREAS, the Monroe County Board of County Commissioners ( "Plan Sponsor ")
sponsors the Monroe County Group Health Plan ( "Plan") effective January 1, 2010; and
WHEREAS, the Plan Sponsor reserves the right to amend the Plan at any time; and
WHEREAS, in light of the adoption of the Patient Protection and Affordable Care Act
( "PPACA "), the Plan must be amended in certain particulars; and
WHEREAS, Amendment #2 to the Plan amended the Plan to include provisions for
"grandfathered health plans "; and
WHEREAS, BOCC is choosing to operate the Plan as if it is no longer a "grandfathered
health plan" as that term is defined in the PPACA and the underlying regulations; and
WHEREAS, BOCC intends to amend the Plan in good faith to comply with PPACA.
NOW, THEREFORE, pursuant to the Plan amendment provisions, the Plan shall be
amended generally effective January 1, 2011 except as otherwise noted as follows:
1. :Page 1 -1: Amend the introductory paragraph of Section 1 by adding the following
sentence at the end:
"'The In- Network Deductible and Coinsurance Amounts and In- Network charges for
Office Services described below will not apply to Preventive Items and Services (as
defined in Section 7 of the Plan) and will be subject to the Special Rules for
Preventive Items and Services under Paragraph C below."
2. Page 1 -2: Section 1 is amended by the adding a new paragraph C, as follows, and by
renaming current paragraphs C, D and E as D, E and F respectively.
"C. PREVENTIVE ITEMS AND SERVICES — SPECIAL RULES
Coverage for Office Visits in Conjunction with Preventive Items and Services
• The Plan may impose cost - sharing requirements with respect to an office visit
if a Preventive Item or Service is billed separately or tracked as individual
encounter data separately from the office visit.
• The Plan shall not impose cost - sharing requirements with respect to an office
visit if a Preventive Item or Service is not billed separately or is not tracked as
individual encounter data separately from the office visit and the primary
purpose of the office visit is the delivery of the item or service.
The Plan may impose cost - sharing requirements with respect to an office visit
if a Preventive Item or Service is not billed separately or is not tracked as
individual encounter data separately from the office visit and the primary
purpose of the office visit is not the delivery of the item or service.
Preventive Items and Services Delivered by Out -of- Network Providers
'The Plan may impose its cost - sharing requirements to Preventive Items and Services
delivered by an Out -of- Network provider.
Reasonable Medical Management
"The Plan will apply its Benefit Utilization Management and Utilization Review
:Programs to Preventive Items and Services."
3. Page 7 -12: A new section entitled "Preventive Items and Services" is added
immediately after "Preventive Child Health Supervision Services" to read as follows:
• "Preventive Items and Services or Preventive Item or Service means:
• Evidence -based items or services that have in effect a rating of A or B in
the recommendations of the United States Preventive Services Task Force
as of September 23, 2010 with respect to the individual involved, as may
change from time to time;
• Immunizations for routine use in children, adolescents and adults that have
in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention
with respect to the individual involved;
• With respect to infants, children and adolescents, evidence - informed
preventive care, and screenings provided for in comprehensive guidelines
supported by the Health Resources and Services Administration; and
• With respect to women, to the extent not already described, evidence -
informed preventive care and screenings provided for in comprehensive
guidelines supported by the Health Resources and Services
Administration."
4. :Page 9 -2: Paragraph 3a of the "Eligibility Requirements for Dependent(s)" subsection
of Section 9 of the Plan is amended to read as follows:
''`a. is under the age of 26 or is still within the Calendar Year in which he or she
reaches age 26; or"
5. ]Page 18 -3: Effective not later than July 1, 2011, the section entitled "Benefit
Determinations on Pre - Service Claims Involving Urgent Care" is amended to read:
" Benefit Determinations on Pre - Service Claims Involving Urgent Care
For a Pre - Service Claim Involving Urgent Care, Wells Fargo TPA will provide notice
of the determination (whether adverse or not) as soon as possible, but not later than
.14 hours after receipt of the Pre - Service Claim unless additional information is
required for a coverage decision. If additional information is necessary to make a
determination, Wells Fargo TPA will provide notice within 24 hours of: 1) the need
for additional information; 2) the specific information that the Covered Plan
Participant or the Covered Plan Participant's Provider may need to provide; and 3)
the date that Wells Fargo TPA reasonably expects to provide notice of the decision.
If Wells Fargo TPA requests additional information, Wells Fargo TPA must receive it
within 48 hours of the request. Wells Fargo TPA will provide notice of the decision
on a Covered Plan Participant's Pre - Service Claim within 48 hours after the earlier
of: 1) receipt of the requested information; or 2) the end of the period that was
afforded to provide the specified additional information as described above."
6. Page 18 -5: Effective not later than July 1, 2011, the "Standards for Adverse Benefit
Determinations" section of the Claims Processing section is amended to read:
" Manner and Content of a Notification of an Adverse Benefit Determination
Wells Fargo TPA will provide notice of any Adverse Benefit Determination in
writing. Notification of an Adverse Benefit Determination will include (or will be
made available to the Covered Plan Participant free of charge upon request):
• information sufficient to identify the claim involved, including the date of
service, the health care provider, the claim amount (if applicable), and the
diagnosis and treatment codes (and an explanation of the meaning of those
codes);
• the specific reason or reasons for the Adverse Benefit Determination;
• new or additional evidence considered, relied upon, or generated by the
Monroe County Group Health Plan Administrator and/or Wells Fargo TPA in
connection with the claim, as well as any new or additional rationale for a
denial at the internal appeals stage, and a reasonable opportunity for the
claimant to respond to such new evidence or rationale;
• a reference to the specific Monroe County Group Health Plan Document
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;
• a description of any additional information that might change the
determination and why that information is necessary;
• a description of the Adverse Benefit Determination review procedures and the
time limits applicable to such procedures;
• if the Adverse Benefit Determination is based on the Medical Necessity or
Experimental or Investigational limitations and exclusions, a statement telling
the Covered Plan Participant how to obtain the specific explanation of the
scientific or clinical judgment for the determination;
• a description of the Covered Plan Participant's appeal rights with respect to
the decision, including a description of the internal and external appeals
review processes; and
• contact information for any applicable office of health insurance consumer
assistance or ombudsman established to assist individuals with appeals
procedures.
If the Covered Plan Participant's claim is a Claim Involving Urgent Care, Wells
Fargo TPA may notify the Covered Plan Participant orally within the proper
timeframes, provided Wells Fargo TPA follows -up with a written or electronic
notification meeting the requirements of this subsection no later than two (2) days
after the oral notification."
7. Page 18 -7: A new "Standard External Review" section is added immediately before
the "Additional Claims Processing Provisions" section to read:
"Standard External Review
Request for External Review
A claimant can file a request for an external review with Wells Fargo TPA if the
request is filed within four months after the date of receipt of a notice of an Adverse
Benefit Determination or final internal Adverse Benefit Determination. If there is no
corresponding date four months after the date of receipt of such a notice, then the
request must be filed by the first day of the fifth month following the receipt of the
notice. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the
last filing date is extended to the next day that is not a Saturday, Sunday, or Federal
holiday.
Preliminary Review
Within five business days following the date of receipt of the external review request,
Wells Fargo TPA will complete a preliminary review of the request to determine
whether:
• the claimant is or was covered under the Plan at the time the health care item
or service was requested, or in the case of a retrospective review, was covered
under the Plan at the time the health care item or service was provided;
• the Adverse Benefit Determination or the final Adverse Benefit Determination
does not relate to the claimant's failure to meet the requirements for eligibility
under the terms of the Plan;
• the claimant has exhausted the Plan's internal appeal process unless the
claimant is not required to exhaust the internal appeals process under the
interim final regulations; and
• the claimant has provided all the information and forms required to process an
external review.
Within one business day after completion of the preliminary review, Wells Fargo
TPA will issue a notification in writing to the claimant. If the request is complete but
not eligible for external review, such notification must include the reasons for its
ineligibility and contact information for the Employee Benefits Security
Administration (toll -free number 866 - 444 -EBSA (3272)). If the request is not
complete, such notification will describe the information or materials needed to make
the request complete and Wells Fargo TPA will allow a claimant to perfect the
request for external review within the four -month filing period or within the 48 -hour
period following the receipt of the notification, whichever is later.
Referral to Independent Review Organization (IRO)
'The Plan will utilize IROs contracted by Wells Fargo TPA.
Documents Considered Under External Review by the IRO
'The IRO will provide the claimant with written notice of the review request's
eligibility and acceptance for external review. Claimants may then submit additional
information in writing to the IRO within ten business days following receipt of the
notice. The IRO may also accept and consider additional information that is
submitted after ten business days, though it is not required to do so. The IRO must
consider such additional information in its external review without deference or
presumption of correctness to the Plan's previous decision or conclusion. In addition
to documents and information provided by the claimant, the IRO will consider the
following items in reaching its decision (to the extent the information is available and
the IRO considers it appropriate):
• The claimant's medical records;
• The recommendation of the attending health care professional;
• Reports from appropriate health care professionals and other documents
submitted by the Plan or insurer, claimant, or the claimant's treating provider;
• The governing Plan terms (to ensure that the IRO's decision is not inconsistent
with the Plan's terms - unless the Plan's terms are contrary to any governing
law);
• Appropriate practice guidelines, which must include applicable evidence-
based standards;
• Any applicable clinical review criteria developed and used by the Plan (unless
the criteria are inconsistent with the Plan terms or applicable law); and
• The opinion of the IRO's clinical reviewer(s).
Notice of IRO's Final External Review Decision
Within 45 days after the IRO receives the external review request, it must provide
written notice of the final external review decision. This notice will be delivered to
both the claimant and the Plan and will include the following:
A general description of the reason for the external review request, including
information sufficient to identify the claim; this information includes the
date(s) of service, the provider, claim amount (if applicable), diagnosis and
treatment codes (and their corresponding meanings), and the reason for the
prior denial;
The date the IRO received the assignment to conduct the external review, and
the date of the IRO's decision;
References to the evidence or documentation considered in reaching the
decision, including specific coverage provisions and evidence -based
standards;
• A discussion of the principal reason(s) for the IRO's decision, including the
rationale for its decision and any evidence -based standards relied on in
making the decision;
• A statement that the IRO's determination is binding, unless other remedies are
available to the Plan or claimant under state or federal law;
• A statement that judicial review may be available to the claimant; and
• The phone number and other current contact information for any applicable
office of health insurance consumer assistance or ombudsman.
Reversal of the Plan's decision
Upon receipt of a notice of a final external review decision reversing the Adverse
Benefit Determination or final internal Adverse Benefit Determination, the Plan
immediately must provide coverage or payment or authorization for payment of the
claim.
Expedited External Review
Request for Expedited External Review
Claimants can request an expedited external review with the Plan in the following
situations:
• When the claimant receives a benefits denial involving a claimant's medical
condition where the timeframe for completing an expedited internal appeal
under the appeals regulations would seriously jeopardize the claimant's life or
health or jeopardize the claimant's ability to regain maximum function and the
claimant has filed an expedited internal appeal request; or
• When the claimant receives a final internal benefits denial involving (i) a
claimant's medical condition where the timeframe for completing standard
external review would seriously jeopardize the claimant's life, health, or
ability to regain maximum function, or (ii) an admission, availability of care,
continued stay, or health care item or service for which the claimant received
emergency services, but has not been discharged from a facility.
8. Page 18 -8: The "Additional Claims Processing Provisions" section is amended to
include the following paragraph:
"7. Conflicts of Interest. Decisions of Wells Fargo TPA regarding hiring,
compensation, termination, promotion, or other similar matters with respect to an
individual such as a claims adjudicator or medical expert will not be based upon
the likelihood the individual will support the denial of benefits."
9. Page 21 -1: The definition of "Adverse Benefit Determination" is amended to include
the following at the end of that section:
"The term Adverse Benefit Determination also includes a rescission of coverage,
which is any retroactive termination of coverage due to fraud or intentional
misrepresentation of material fact."
PASSED AND ADOPTED by the Board of County Commissioners of Monroe County,
Florida, at a regular meeting of said Board held on the 1 9 + " day Of .Jatnuo r L _, 2011.
May or Heather Carruthers
Mayor Pro Tem David Rice
Commissioner George Neugent
Commissioner Sylvia Murphy
Commissioner Kim Wigington
SEAL:
Attest
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BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By:
May r /Chairperson
MO OE COUNTY ATTORNEY
'-,u
ROV AS �,
CYNTHIA L. NA L
ASSIS A NT CCf Y ATTORNEY Date �' ` w___—