Item H1�Klffxll 11, 010 10 NA!"416
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Bulk Item: Yes No X
#1 •
AGENDA ITEM WORDING: Approval to advertise a Request for Proposals for Medical Plan
Administration on a Self Funded or Fully Insured Basis, including: Claims Administration, Utilization
Review, Large Case Management, Disease Management, Network Management, Pharmacy Benefit
Management, Wellness Programs and/or Stop Loss Insurance.
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $800 INDIRECT COST: BUDGETED: Yes X No
DIFFERENTIAL OF LOCAL PREFERENCE:
COST TO COUNTY: SOURCE OF FUNDS:
REVENUE PRODUCING: Yes N AMOUNT PER MONTH Year
APPROVED BY: County Att /Purchasing — Risk Management
DOCUMENTATION: Include Not Required
1011SPOSITION: AGENDAITEM#
Revised 7109
MONROE COUNTY
REQUEST FOR PROPOSALS
FOR
Medical Plan Administration on a Self Funded or
Fully Insured Basis, including: Claims
Administration, Utilization Review, Large Case
Management, Disease Management, Network
Management, Pharmacy Benefit Management,
Wellness Programs, and /or Stop Loss Insurance.
BOARD OF COUNTY COMMISSIONERS
Mayor, Heather Carruthers, District 3
Mayor Pro Tern, David Rice, District 4
Commissioner Kim Wigington, District 1
Commissioner George Neugent, District 2
Commissioner Sylvia Murphy, District 5
COUNTY ADMINISTRATOR
Roman Gastesi
CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION
Danny L. Kolhage Teresa Aguiar, Director
February 25, 2011
NOTICE OF REQUEST FOR PROPOSALS
Request for Proposals
Medical Plan Administration on a Self Funded or Fully Insured Basis,
including: Claims Administration, Utilization Review, Large Case
Management, Disease Management, Network Management,
Pharmacy Benefit Management, Wellness Programs, and /or Stop Loss
Insurance.
#RFP -PER- - PUR /CV
The Board of County Commissioners of Monroe County, Florida, hereby
requests sealed proposals from applicants who wish to provide any or all of the
following services: Third Party Administration, Claims Administration, Utilization
Review, Disease Management, Large Case Management, Network Provider
Services, Pharmacy and /or Stop Loss Insurance, or to provide a fully insured
traditional group health insurance plan.
Proposers may choose to submit plans for the existing self- insured medical
benefits plan or for a fully insured traditional group medical benefits plan.
Proposers may also submit proposals for both the self- insured support services
and a traditional fully insured medical benefits plan provided that they are
separate stand alone proposals. In the case where multiple proposals are
submitted, each proposal should be made as a separate proposal and specifically
marked as an individual proposal.
Interested firms or individuals are requested to indicate their interest by
submitting three (3) signed originals, one complete set of responses in an
electronic format compatible with Microsoft Excel or Word (PDF responses will not
be deemed responsive) and five (5) complete copies (total = eight (8) plus
electronic format) of the proposal, in a sealed envelope clearly marked on the
outside, with the Proposer's name and "Medical Plan Administration
Proposal ", addressed to Monroe County Purchasing Department, 1100 Simonton
Street, Room 1 -213, Key West, FL 33040, which must be received on or before
3:00 P.M. local time on March 31, 2011. Hand delivered Proposals may request a
receipt. No proposals will be accepted after 3:00 P.M. Faxed or e- mailed
proposals shall be automatically rejected. It is the sole responsibility of each
Proposer to ensure its proposal is received in a timely fashion.
Requirements for submission and the selection criteria may be requested
from DemandStar by Onvia by calling 1- 800 - 711 -1712 or by going to the website
www.demandstar.com or
http: / /www.demandstar.com /supplier /bids /agency inc /bid 1ist.asp ?f= search &mi =1
16478
The Public Record is available at the Purchasing Office, 1100 Simonton Street,
Key West, Florida.
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All submissions must remain valid for a period of one hundred twenty (120)
days from the date of the deadline for submission stated above. The Board
will automatically reject the response of any person or affiliate who appears on
the convicted vendor list prepared by the Department of Management
Services, State of Florida, under Sec. 287.133(3)(d), Florida Statutes. Monroe
County declares that all or portions of the documents and work papers and
other forms of deliverables pursuant to this request shall be subject to reuse by
the County.
Questions are to be directed, in writing to:
Maria Fernandez - Gonzalez, Sr. Benefits Administrator
Monroe County BOCC
1100 Simonton Street, Suite 2 -268
Key West, FL 33040
Facsimile (305) 292 -4452
The Board reserves the right to reject any or all proposals, to waive
informalities in the proposals or to re- advertise for proposals for all or part
of the work completed. The Board also reserves the right to separately
accept or reject any item or items of a proposal, or portion of the work, and
to award and /or negotiate a contract in the best interest of the County. It is
possible that one or more Proposers will be chosen.
Interested firms or individuals will be evaluated and selected by a Selection
Committee. The selection and recommendation will be presented to the Board of
County Commissioners for final decision. If no contract can be negotiated with the
first ranked Proposer, the Board reserves the right to negotiate with the next
ranked Proposer.
Dated at Key West, this day of , 2011
Monroe County Purchasing Department
TABLE OF CONTENTS
NOTICE OF REQUEST FOR PROPOSALS
SECTION ONE -
SECTION TWO -
ATTACHMENT A
SECTION THREE
SECTION FOUR -
SECTION FIVE -
ATTACHMENTS:
Instruction to Proposers
Draft Agreement
Scope of Services
County Forms and Insurance Forms
Questionnaires
Pricing Exhibits
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C. Claims & Enrollment by Month (2009/2010,
2008/2009. 2007/2008)
D. Current Census Information
E. Rates (2009/2010, 2008/2009, 2007/2008)
F. Claims Processed Statistics (5 pages)
G. Large Loss Report — Medical (2009/2010,
2008/2009, 2007/2008)
H. Medical Pricing Form
I. Pharmacy Re- pricing Data File
J. Re- Pricing Summary Report, with Instructions
K. Top Drug Exhibits, with Instructions
L. Specialty Drug Exhibit, with Instructions
M. MAC List, Instructions and Sample
SECTION ONE: INSTRUCTION TO PROPOSERS
1. OBJECTIVE OF THE REQUEST FOR PROPOSAL
The Monroe County Board of County Commissioners wishes to receive competitive
proposals for its PPO Medical Plan Administration, including: claim management, case
management and utilization review services, Disease Management, Pharmacy Benefit
Management, Network Management, Wellness Programs, Stop Loss Insurance, and other
related services as set out in the Scope of Services — Attachment "A" for its current Self -
insured Medical Benefits Plan. MCBCC is also seeking fully insured proposals that will
offer the same or similar benefits being offered in the existing plan. It is understood that a
fully insured plan may not be able to be administered exactly the way the current plan is
administered. In this case proposers are requested to quote their closest plans, and
outline deviations under TAB 3. Special consideration will be given to proposals that will
allow the County to contain costs and provide a seamless, coordinated process, while
providing medical benefits at least equal to the current benefit schedule.
While it is critical to the County that the overall medical plan is well coordinated and
effective in the delivery of services to its employees, retirees, and their dependents,
it is not necessary that all of the benefit activities listed in this RFP be provided by
one proposer. Proposers may submit proposals for individual services or
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administration and may utilize different providers (i.e. Network Management,
Pharmacy Benefit Providers, Disease Management, etc.); however, they must
demonstrate that they can effectively coordinate with other service providers, how
they can integrate necessary data, and what the administrative cost of this
integration will be.
The desired implementation date for the contract is October 1, 2011. The initial contract
term will be for three (3) years upon the approval by the Board of County Commissioners
or as soon thereafter as is possible and renewable at the County's option for two (2)
additional consecutive 1 year terms.
2. CALENDAR
Date
Activity
February 25, 2011
RFP Release Date
March 11, 2011
Deadline for written questions
March 18, 2011
Addendum Release Date
March 31, 2011
Bid Opening — 3:00 P.M. No late bids will be accepted
May 19, 2011
Selection Committee Review Meeting — Public Meeting
May 20, 2011
Selection Committee Ranking & Short Listing — Public - Meetin
May 24 and 25, 2011
Finalist Interviews, if necessary — Public Meetin
June 15, 2011
MCBOCC Board Meeting —Award Bid
October 1, 2011
Contract Effective Date
3. BACKGROUND INFORMATION
Monroe County ( "County ") is a non - chartered county established under the
Constitution and the laws of the State of Florida. The Clerk of the Circuit Court serves
as the fiscal agent. The population of the County is estimated at approximately 75,000.
The Board of County Commissioners, constituted as the governing body, has all the
powers of a body corporate, including the powers to contract; to sue and be sued; to
acquire, purchase, hold, lease and convey real estate and personal property; to borrow
money and to generally exercise the powers of a public authority organized and existing
for the purpose of providing community services to citizens within its territorial
boundaries. In order to carry out this function, the County is empowered to levy taxes to
pay the cost of operations.
The Present Plans
Monroe County currently offers one PPO self- insured plan to its employees, retirees,
and dependants. Plan benefits are shown in Exhibit B. The anniversary date for the
plan year is January 1.
Keys Physician - Hospital Alliance (KPHA) currently performs Pre - certification /Utilization
Review and Large Case Management, in addition to being the local network provider.
Quarterly meetings with KPHA and the third party administrator are held to review the
status of the group health plan. Out -of- county network services are provided through
Dimension Health Plus PPO network in Dade, Broward and Palm Beach Counties. A
nationwide wrap- around, Multiplan, is used for benefit services not included in the
other two networks.
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Wells Fargo has been serving as the County's Third Party Claims Administrator (TPA),
since 1996. Claim processing is handled on a direct submission basis. Claims are
sent directly from the three PPO provider network practitioners to Wells Fargo, which
reviews them for eligibility and processes them for payment along with providing the
Explanation of Benefits (EOB's). Wells Fargo prints claim checks for the County on its
local checking account and forwards the checks directly to the employee or provider.
The claim registers are then forwarded to the County for monitoring. Periodic claim
audits are performed by the County and separately by the TPA. Wells Fargo
maintains a maximum thirty (30) day claim turn around.
The County was covered by a stop loss policy, including both Specific and Aggregate
insurance, until it cancelled the coverage in 2001 and assumed the full risk for its PPO
Medical Plan.
All BOCC employees as well as employees of the five Constitutional Officers (Clerk of
Courts, Sheriff's Office, Tax Collector, Property Appraiser, Supervisor of Elections), the
Land Authority, and eligible retirees, spouses and other dependants participate in
these programs.
Total number of participants is approximately
1256
active employees
608
(estimate) dependents
21
surviving spouses
341
retirees
3
COBRA participants.
Employer contributes 100% of the cost of the Health Plan for active employees and
also subsidizes approximately 60% to 80% of the dependent and retiree premiums.
The current (as of January 1, 2011) employee funding allocation is $790 per month
per employee. Employee contributions for dependents are made through payroll
deductions. See Attachment "E" for a breakdown of rates. Domestic Partners are
considered by County Resolution to be included as dependents subject to the criteria
in the resolution which is included in the Health Plan Document (Attachment "B ").
Medical benefits and Pharmacy benefits are outlined in the Health Plan Document -
Attachment "B ".
Prescription benefits are currently self- insured and included in the overall medical
plan. Walgreens Health Initiatives (WHI) currently manages the prescription plan.
Current Pharmacy Benefits are based on a copayment arrangement as follows:
Generic: $10 for 30 day supply$25 for Mail Order up to 90 days
Preferred Brand: $25 for up to 30 days $62.50 Mail Order up to 90 days
Non Preferred: $70 for up to 30 days $175 Mail Order up to 90 days
"Advantage 90" allows for the purchase of 90 day supplies of maintenance drugs at
select Retail Pharmacies.
Generics are mandatory, with the participant responsible for 100% of the cost of the
Brand drug if there is a generic substitution available and allowable. There is an
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exception to the mandatory generic penalty if the medical provider indicates
"dispense as written" on the prescription.
There are several cost control components to the Rx program. These are explained
in Attachment "B ".
Health benefits currently include the following cost containment provisions:
• Coordination of Benefits
• Subrogation /Right of Reimbursement
• Mandatory Pre - Admission Certification
• Mandatory Diagnostic Certification
• Medical Case Management
• Reduced benefits for out -of- network services
• Mandatory Generics for prescriptions
• Step Therapy
• Clinical prior authorization for certain prescriptions
4. SCOPE OF SERVICES TO BE PROVIDED BY PROPOSER
The scope of services is defined in Attachment "A" to the Draft Agreement
5. NOTICE OF POSSIBLE INTERVIEW
The County may wish to interview finalists in Key West on May 24 or May 25
2011. Proposers who are to be invited for finalist interviews will be notified no later
than May 20, 2011 (specific instructions regarding the presentation will be provided
no later than May 20, 2011) and should be committed to accommodating this time
frame to meet in Key West. Staff present should include all key staff with direct
client responsibilities for the MCBCC account, as well as an individual who is
authorized to contractually obligate the firm.
6. PAYMENT TERMS
The contractor shall submit to the County an invoice with supporting
documentation acceptable to the Clerk on a schedule as set forth in the
contract. Acceptability to the Clerk is based on generally accepted
accounting principles and such laws, rules and regulations as may govern
the Clerk's disbursal of funds, including primarily the Florida Local
Government Prompt Payment Act.
The contractor will submit such invoice monthly for services provided
during the preceding month.
Upon receipt of the contractor's invoice in the proper form as stipulated
above and upon acceptance by the Clerk, Monroe County will make
payment in accordance with the Florida Local Government Prompt
Payment Act, Section 218.70, Florida Statutes.
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7. EVALUATION CRITERIA
Each proposal will be reviewed and consideration will be given to each of the following
criteria:
A. Responsiveness to the RFP Questions and Format requirements
1. Responsiveness to Questions
2. Submission of Required County Forms
3. Follows Required Format
4. Provides required submissions in appropriate format (Word or
Excel)
B. Ability to provide services listed and to ensure the effective coordination
of all required services.
a. The qualifications of the Proposer and professional staff.
(Licenses, Experience, Insurance)
b. Experience with Governmental entities and employers of similar
size as Monroe County.
c. Experience, training and education of staff (including Network
Credentialing)
d. Availability of staff
e. Financial stability of the Proposer.
C. Price. (Three (3) year rate is preferred with maximums or caps for years
two and three.)
1. Three year price guarantee
2. Estimated savings (Administrative fees, network discounts, cost
management, etc.)
D. Performance Guarantees.
E. Location of firm — Local Preference.
F. Overall value to the County (The County reserves the right to request
that Proposers of Network Management Services complete a Medical
Claims Repricing Worksheet at a later time, based on actual claims of the
County).
8. TERMINATION /NON- RENEWAL NOTICE
Ninety (90) days written notice is required by the service provider for termination or non -
renewal of the contract. The County must provide the Contractor with at least sixty (60)
days' notice of intent to terminate
COUNTY may terminate this Agreement with or without cause upon sixty (60) days notice
to the CONTRACTOR. COUNTY shall pay CONTRACTOR for work performed through
the date of termination.
9. REQUEST FOR ADDITIONAL INFORMATION
Request for additional information relating to the specifications of this Request for
Proposals shall be submitted in writing directly to:
Maria Fernandez - Gonzalez, Sr. Benefits Administrator
Monroe County BOCC
1100 Simonton Street, Suite 2 -268
Key West, FL 33040
Facsimile (305) 292 -4452
All requests must be received no later than March 11, 2011. If necessary, one or more
addenda to the RFP will be issued shortly thereafter and distributed to all interested
Proposers. Oral requests will not be answered.
10. CONTENT OF SUBMISSION
The proposal submitted in response to this Request for Proposals (RFP) shall be printed
on 8 -1/2" x 11" white paper and bound; shall be clear and concise, tabulated, and provide
the information requested herein. Proposals submitted without the required information as
defined in this RFP will not be considered. Responses shall be organized as indicated
below. The Proposer should not withhold any information from the written response in
anticipation of presenting the information orally or in a demonstration, since oral
presentations or demonstrations may not be solicited. Each Proposer must submit
adequate documentation to certify the Proposer's compliance with the County's
requirements. Proposers should focus specifically on the information requested.
Separate Questionnaires (Section Four) are included for various provider services and
must be completed for each benefit service.
Format. The response shall include the following sections and shall provide brief and
clear responses to each item within the sections. The Selection Committee will not be
impressed by excessive verbiage or general, boilerplate language in the responses.
A. Cover Page
A cover page that states Proposal for: "Medical Plan Administration on a Self Funded or Fully
Insured Basis, including: Claims Administration, Utilization Review, Large Case
Management, Disease Management, Network Management, Pharmacy Benefit
Management, Wellness Programs, and /or Stop Loss Insurance ". The cover page should
contain the RPF Identification Number, Proposer's name, address, telephone number, and the
name of the Proposer's contact person.
B. Tabbed Sections — For Proposers submitting proposals for multiple services under
this RFP using subcontractors or a coordinated bid with several vendors, it is required that
all of the following information be completed for each separate vendor. If a Proposer is
submitting one proposal with no subcontractors or outside vendors, then this information
is required only once.
Tab 1. General Information
(a) The name of the firm submitting proposal, address, contact person's name, telephone
numbers, email address and the name of the individual authorized to sign for the
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proposing organization.
(b) A clear statement of what service or fully insured medical benefit plan is being proposed. If
more than one type of service or plan is proposed, separate proposals must be
made for each one so that they can be reviewed independently of any other service
or benefit plan. If a single entity is proposing more than one service, a separate
questionnaire must be completed for each service proposed under one proposal
cover.
(c) Copies of the appropriate state / county licenses and authorizations, as well as proof of all
accreditations.
(d) Resumes of all key members of the account team who will be assigned including
professional designations and copies of licenses and diplomas.
Tab 2. Relevant Experience
Provide an overview of the Proposer's experience that demonstrates a record of performance and
professional accomplishments by the Proposer and employees. Highlight proficiency in working
with governmental entities. Focus specifically on providing information to demonstrate capabilities
in coordinated medical plan administration across the full range of services requested in this RFP.
Customer references: The Proposer shall provide a list of similar contracts or agreements
currently in force (no more than four Florida government clients) to include:
• Name and full address of client
• Number of employees
• Name and Title of client contact
• Telephone number and email address of client contact
• Date of initiation of contract
• Summary of the services and area served
Tab 3. Services, Scope of Services, and Deviations
(a) The Proposer shall clearly describe the specific services that are being offered
in the proposal. This shall include information on schedules and availability of
staff, whether sub - contractors are used, how the services will be integrated and
any other relevant information explaining how the services will be
accomplished in a coordinated manner.
(b) The Proposer shall respond to the delivery of individual services listed in the
Scope of Services to be Provided by Proposer (Attachment A to the Draft
Agreement) in this RFP. The Proposer should respond by checking the
appropriate box in Attachment A, and providing detail as needed in the
deviations column.
(c) The Proposer must clearly outline deviations to any of the provisions of this
RFP under Tab 3
Tab 4. Litigation
Provide answers to the following questions regarding claims and suits:
(a) Has the Proposer ever failed to complete work or provide the goods for which it has
contracted? (If yes, provide details.)
(b) Are there any judgments, claims, arbitration proceeding or suits pending or
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outstanding against the Proposer, or its officers or general partners? (If yes, provide
details.)
(c) Has the Proposer, within the last five (5) years, been a party to any lawsuit or
arbitration with regard to a contract for services, goods or construction services similar
to those requested in the RFP? (If yes, the Proposer shall provide a history of any past
or pending claims and litigation in which the Proposer is involved as a result of the
provision of the same or similar services which are requested or described herein.)
(d) Has the Proposer ever initiated litigation against the County or been sued by the
County in connection with a contract to provide services, goods or construction
services? (If yes, provide details.)
(e) Whether, within the last five (5) years, an officer, general partner, controlling
shareholder or major creditor of the Proposer was an officer, general partner,
controlling shareholder or major creditor of any other entity that failed to perform
services or furnish goods similar to those sought in the request for bids.
Tab 5. Questionnaire
Proposer shall complete each of the appropriate portions of Section Four for every
service the Proposer is offering and include the responses in this tab. Each
Questionnaire must be included in the format provided in this RFP.
Tab 6 — Pricing Exhibits
Proposers shall complete the appropriate Pricing Exhibit(s) for each of the services
the Proposer is offering and include the responses in this tab. The Pricing Exhibit
must be included in the format provided in this RFP and must clearly indicate all
proposed charges for services offered to MCBCC. The pricing for fully insured
proposals is not required to follow the County's current pricing structure for its
medical plan. The County is requesting a four tier rate structure as outlined in the
pricing exhibit.
Important information for PBM Proposers The following pricing information
and completed Exhibits are to be sent directly to the National Pharmacy
Management division to:
Michael E Thomas, Phann.D.
GBS, National Pharmacy Mgmt
2254 Valley Road
Chesterfield, MO 63005
Voice: (636) 532 -3713
Fax: (636) 536 -2450
drmike c ,aj g. com
Attachment I — Pharmacy Re- Pricing Data File
Attachment J — Re- Pricing Summary Report, with Instructions
Attachment K — Top Drug Exhibits, with Instructions
Attachment L — Specialty Drug Exhibit, with Instructions
Attachment M — MAC List, Instructions and Sample
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All other proposal documents are to be sent, in the required form and format, to the
Monroe County Board of County Commissioners address as specified in the RFP.
Tab 6. County Forms and Licenses
Proposer shall complete and execute the forms specified below and located in Section
Three in this RFP, -and shall include them in this section, i.e. Tab 6:
Forms
Lobbying and Conflict of Interest Ethics Clause
Local Preference Form, if applicable
Non - Collusion Affidavit
Drug Free Workplace Form
Proposer's Insurance and Indemnification Statement
Insurance Agent's Statement
11. COPIES OF RFP DOCUMENTS
A. Only complete sets of RFP Documents will be issued and shall be used in
preparing responses. The County does not assume any responsibility for
errors or misinterpretations resulting from the use of incomplete sets.
B. Complete sets of RFP Documents may be obtained in the manner and at
the locations stated in the Notice of Request for Proposals.
12. STATEMENT OF PROPOSAL REQUIREMENTS
Interested firms or individuals are requested to indicate their interest by
submitting three (3) signed originals, one complete set of responses in an
electronic format compatible with Microsoft Excel or Word (PDF responses will not
be deemed responsive) and five (5) complete copies (total = eight (8) plus
electronic copy) of the proposal, in a sealed envelope clearly marked on the
outside, with the Proposer's name and "Medical Plan Administration
Proposal ", addressed to Monroe County Purchasing Department, 1100 Simonton
Street, Room 1 -213, Key West, FL 33040, which must be received on or before
3:00 P.M. local time on March 31, 2011. Hand delivered Proposals may request a
receipt. No proposals will be accepted after 3:00 P.M. Faxed or e- mailed
proposals shall be automatically rejected. It is the sole responsibility of each
Proposer to ensure its proposal is received in a timely fashion.
13. DISQUALIFICATION OF PROPOSER
A. NON - COLLUSION AFFIDAVIT: Any person submitting a proposal in
response to this invitation must execute the enclosed NON - COLLUSION
AFFIDAVIT. If it is discovered that collusion exists among the Proposers,
the proposals of all participants in such collusion shall be rejected, and no
participants in such collusion will be considered in future proposals for the
same work.
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B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the
convicted vendor list following a conviction for a public entity crime may not
submit a proposal on a contract to provide any goods or services to a public
entity, may not submit a proposal on a contract with a public entity for the
construction or repair of a public building or public work, may not submit
Proposals on leases or perform work as a contractor, supplier,
subcontractor, or contractor under a contract with any public entity, and
may not transact business with any public entity in excess of the threshold
amount provided in Section 287.017, Florida Statutes, for CATEGORY
TWO for a period of 36 months from the date of being placed on the
convicted vendor list. Category Two: $25,000.00
C. DRUG -FREE WORKPLACE FORM: Any person submitting a bid or
proposal in response to this invitation must execute the enclosed DRUG -
FREE WORKPLACE FORM and submit it with his /her proposal. Failure to
complete this form in every detail and submit it with the bid or proposal
may result in immediate disqualification of the bid or proposal.
D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any
person submitting a bid or proposal in response to this invitation must
execute the enclosed LOBBYING AND CONFLICT OF INTEREST
CLAUSE and submit it with his /her bid or proposal. Failure to complete this
form in every detail and submit it with the bid or proposal may result in
immediate disqualification of the bid or proposal.
14. EXAMINATION OF RFP DOCUMENTS
A. Each Proposer shall carefully examine the RFP and other contract
documents, and inform himself /herself thoroughly regarding any and all
conditions and requirements that may in any manner affect cost, progress,
or performance of the work to be performed under the contract. Ignorance
on the part of the Proposer shall in no way relieve him /her of the obligations
and responsibilities assumed under the contract.
B. Should a Proposer find discrepancies or ambiguities in, or omissions from,
the specifications, or should he be in doubt as to their meaning, he shall at
once notify the County.
15. INTERPRETATIONS, CLARIFICATIONS, AND ADDENDUM
No oral interpretations will be made to any Proposer as to the meaning of the contract
documents. Any inquiry or request for interpretation received no later than close of
business on March 11, 2011 -will be answered. All such inquiries or requests for
interpretation will be made in writing in the form of an addendum and, if issued, will be
furnished to all known prospective Proposers prior to the established Proposal opening
date. Each Proposer shall acknowledge receipt of such addenda in his /her Proposal. In
case any Proposer fails to acknowledge receipt of such addenda or addendum, his /her
response will nevertheless be construed as though it had been received and
acknowledged and the submission of his /her response will constitute acknowledgment of
the receipt of same. All addenda are a part of the contract documents and each Proposer
will be bound by such addenda, whether or not received by him /her. It is the responsibility
of each Proposer to verify that he /she has received all addenda issued before responses
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are opened.
16. GOVERNING LAWS AND REGULATIONS
The Proposer is required to be familiar with and shall be responsible for complying with all
federal, state, and local laws, ordinances, rules, professional license requirements and
regulations that in any manner affect the work. Knowledge of business tax requirements
and obtaining such licenses for Monroe County and municipalities within Monroe County
are the responsibility of the Proposer.
17. PREPARATION OF RESPONSES
Signature of the Proposer: The Proposer must sign the response forms in the space
provided for the signature. If the Proposer is an individual, the words "doing business as
or "Sole Owner" must appear beneath such signature. In the case of a
partnership, the signature of at least one of the partners must follow the firm name and the
words "Member of the Firm" should be written beneath such signature. If the Proposer is a
corporation, the title of the officer signing the Response on behalf of the corporation must
be stated and evidence of his authority to sign the Response must be submitted. The
Proposer shall state in the response the name and address of each person having an
interest in the submitting entity.
18. MODIFICATION OF RESPONSES
Written modification will be accepted from Proposers if addressed to the entity and
address indicated in the Notice of Request for Proposals and received prior to Proposal
due date and time. Modifications must be submitted in a sealed envelope clearly marked
on the outside with the Proposer's name and "Modification to Proposal - Medical Plan
Administration ". If sent by mail or by courier, the above - mentioned envelope shall be
enclosed in another envelope addressed to the entity and address stated in the Notice of
Request for Proposals. Faxed or e- mailed modifications shall be automatically rejected.
19. RESPONSIBILITY FOR RESPONSE
The Proposer is solely responsible for all costs of preparing and submitting the response,
regardless of whether a contract award is made by the County.
20. RECEIPT AND OPENING OF RESPONSES
Responses will be received until the designated time and will be publicly opened.
Proposers' names shall be read aloud at the appointed time and place stated in the
Notice of Request for Proposals. Monroe County's representative authorized to open
the responses will decide when the specified time has arrived and no responses received
thereafter will be considered. No responsibility will be attached to anyone for the
premature opening of a response not properly addressed and identified. Proposers or their
authorized agents are invited to be present.
21. DETERMINATION OF SUCCESSFUL PROPOSER
The contract shall be awarded based on the following criteria, which may be inclusive of,
but not limited to the items listed:
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Criteria
Maximum Points
A. Responsiveness to the RFP Questions and
10
Format requirements
1. Responsiveness to Questions
2. Submission of Required County Forms
3. Follows Required Format
4. Provides required submissions in
appropriate format (Word or Excel)
B. Ability to provide services listed and to ensure
30
the effective coordination of all required
services.
1. The qualifications of the Proposer and
professional staff. (Licenses,
Experience, Insurance)
2. Experience with Governmental entities
and employers of similar size as
Monroe County.
3. Experience, training and education of
staff (including Network Credentialing)
4. Availability of staff
5. Financial stability of the Proposer.
C. Price. (Three (3) year rate is preferred with
20
maximums or caps for years two and three.)
1. Three year price guarantee
2. Estimated savings (Administrative
fees, network discounts, cost
management, etc.)
D. Performance Guarantees.
10
E. Location of firm — Local Preference
5
Scoring for Local Preference is either 5 or 0.
F. Overall value to the County (The County
25
reserves the right to request that Proposers of
Network Management Services complete a
Medical Claims Repricing Worksheet at a
later time, based on actual claims of the
County)
Maximum points available 100 points if local
preference is confirmed. 95 points if no local
preference.
Lowest = 0 Highest = 100
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The County reserves the right to reject any and all responses and to waive technical errors
and irregularities as may be deemed best for the interests of the County. Responses that
contain modifications are incomplete, unbalanced, conditional, obscure, or that contain
additions not requested or irregularities of any kind, or that do not comply in every respect
with the Instruction to Proposer and the contract documents, may be rejected at the option
of the County.
22. AWARD OF CONTRACT
A. The County reserves the right to award separate contracts for the services
based on geographic area or other logical distinctions, and to waive any informality in any
response, or to re- advertise for all or part of the work contemplated. It is possible that one
or more Proposers will be chosen.
B. The County also reserves the right to reject the response of a Proposer
who has previously failed to perform properly or to complete contracts of a similar nature
on time.
C. The recommendation of the Selection Committee will be presented to the
Board of County Commissioners of Monroe County, Florida, for final selection and award
of contract.
23. CERTIFICATE OF INSURANCE AND INSURANCE REQUIREMENTS
The Proposer shall be responsible for all necessary insurance coverage as indicated
below. Certificates of Insurance must be provided to Monroe County within fifteen (15)
days after award of contract, with Monroe County BOCC listed as additional insured as
indicated. If the proper insurance forms are not received within the fifteen (15) day period,
the contract may be awarded to the next selected Proposer. Policies shall be written by
companies licensed to do business in the State of Florida and having an agent for service
of process in the State of Florida. Companies shall have an A.M. Best rating of VI or better
and a financial rating of A- from A.M. Best. The required insurance shall be maintained at
all times while Proposer is providing service to County.
Worker's Compensation
Employers' Liability
General Liability, including
Professional Liability
Statutory Limits
$500,000
$300,000 combined single limit
$1,000,000 per occurrence
Monroe County shall be named as an Additional Insured on the General Liability
policy.
24. INDEMNIFICATION
The Proposer to whom a contract is awarded shall defend, indemnify and hold harmless
the County as outlined below.
The Proposer covenants and agrees to indemnify, hold harmless and defend Monroe
County, its commissioners, officers, employees, agents and servants from any and all
claims for bodily injury, including death, personal injury, and property damage, including
damage to property owned by Monroe County, and any other losses, damages, and
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expenses of any kind, including attorney's fees, court costs and expenses, which arise
out of, in connection with, or by reason of services provided by the Proposer or any of its
Subcontractor(s), occasioned by the negligence, errors, or other wrongful act or
omission of the Proposer, its Subcontractor(s), their officers, employees, servants or
agents.
In the event that the service is delayed or suspended as a result of the Vendor's failure
to purchase or maintain the required insurance, the Vendor shall indemnify the County
from any and all increased expenses resulting from such delay.
The first ten dollars ($10.00) of remuneration paid to the Proposer is consideration for
the indemnification provided for above. The extent of liability is in no way limited to,
reduced, or lessened by the insurance requirements contained elsewhere within this
agreement.
25. EXECUTION OF CONTRACT
The Proposer will be required to execute a contract with the County for the services
provided for in this RFP. The Proposer with whom a contract is negotiated shall be
required to return to the County four (4) executed counterparts of the prescribed Contract
together with the required certificates of insurance. A Draft of the contract is attached in
Section Two.
If the Proposer cannot fully comply with any of the terms contained in the draft contract,
shown in Section Two, all deviations to the terms must be spelled out in Tab 3, under
Deviations.
26. OWNERSHIP OF INFORMATION
All information and files are required to be returned to the County within thirty (30)
days after termination of the contract or upon request by the County. All files are
the property of the County. The TPA will be responsible for the transfer of data to
another TPA or to the County in the event the TPA contract is not continued. The
TPA must agree that all prior claim history in electronic form will be available. Any
additional charges or fees must be specifically identified at the time the proposal is
accepted.
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SECTION TWO: DRAFT AGREEMENT
MONROE COUNTY
CONTRACT FOR
Services
THIS AGREEMENT is made and entered into this day of , by
MONROE COUNTY ( "COUNTY "), a political subdivision of the State of Florida, whose
address is 1100 Simonton Street, Key West, Florida 33040 and
( "CONTRACTOR "), whose address is
Section 1. SCOPE OF SERVICES
CONTRACTOR shall do, perform and carry out in a professional and proper manner
certain duties as described in the Scope of Services — Attachment A — which is attached
hereto and made a part of this agreement.
CONTRACTOR shall provide the scope of services in Exhibit A for COUNTY.
CONTRACTOR warrants that it is authorized by law to engage in the performance of the
activities herein described, subject to the terms and conditions set forth in these
Agreement documents. The CONTRACTOR shall at all times exercise independent,
professional judgment and shall assume professional responsibility for the services to be
provided. Contractor shall provide services using the following standards, as a minimum
requirement:
A. The CONTRACTOR shall maintain adequate staffing levels to provide the
services required under the Agreement.
B. The personnel shall not be employees of or have any contractual
relationship with the County. To the extent that Contractor uses
subcontractors or independent contractors, this Agreement specifically
requires that subcontractors and independent contractors shall not be an
employee of or have any contractual relationship with County.
C. All personnel engaged in performing services under this Agreement shall
be fully qualified, and, if required, to be authorized or permitted under State
and local law to perform such services.
Section 2. COUNTY'S RESPONSIBILITIES
2.1 Provide all best available information as to the COUNTY'S requirements for the
scope of services described in Exhibit A to this Agreement.
2.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all
matters concerning said services.
2.3 Provide a schedule that is mutually agreeable to the COUNTY and
CONTRACTOR.
Section 3. TERM OF AGREEMENT
3.1 The initial Agreement term will be for three (3) years beginning the _ day of
, 2011 and renewable at the County's option for two (2)
additional consecutive one year terms.
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3.2 The terms of this Agreement shall be from the effective date hereof and continue for
a period of three (3) years. This Agreement shall be automatically renewed for
successive one -year periods until either party gives the other notice of cancellation
in accordance with the terms set forth below. The Contractor must provide at least
ninety (90) days' notice of intent to terminate. The County must provide the
Contractor with at least sixty (60) days' notice of intent to terminate. If either party
desires to modify this Agreement, it shall notify the other in writing at least sixty
(60) days prior to the effective date of such modification. In the case of proposed
modification the party receiving the notification of the proposed modification shall
itself notify the other party within ten (10) days after receipt of notice of its
agreement to the proposed modification. Failure to do so shall terminate this
Agreement.
Section 4. COMPENSATION
Compensation to CONTRACTOR shall be $
Section 5. PAYMENT TO CONTRACTOR
5.1 Payment will be made according to the Florida Local Government Prompt Payment
Act. Any request for payment must be in a form satisfactory to the Clerk of Courts
for Monroe County (Clerk). The request must describe in detail the services
performed and the payment amount requested. The CONTRACTOR must submit
invoices to the appropriate offices marked . The
respective office supervisor and the Director of Employee Services, who will review
the request, note his /her approval on the request and forward it to the Clerk for
payment.
5.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe
County.
Section 6. CONTRACT TERMINATION
Either party may terminate this Agreement because of the failure of the other party to
perform its obligations under the Agreement. COUNTY may terminate this Agreement
with or without cause upon sixty (60) days notice to the CONTRACTOR. COUNTY shall
pay CONTRACTOR for work performed through the date of termination.
Section 7. CONTRACTOR'S ACCEPTANCE OF CONDITIONS
A. CONTRACTOR hereby agrees that he has carefully examined the RFP, his
response, and this Agreement and has made a determination that he /she has the
personnel, equipment, and other requirements suitable to perform this work and
assumes full responsibility therefore. The provisions of the Agreement shall
control any inconsistent provisions contained in the specifications. All
specifications have been read and carefully considered by CONTRACTOR, who
understands the same and agrees to their sufficiency for the work to be done.
Under no circumstances, conditions, or situations shall this Agreement be more
strongly construed against COUNTY than against CONTRACTOR.
B. Any ambiguity or uncertainty in the specifications shall be interpreted and
construed by COUNTY, and its decision shall be final and binding upon all parties.
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C. The passing, approval, and /or acceptance by COUNTY of any of the services
furnished by CONTRACTOR shall not operate as a waiver by COUNTY of strict
compliance with the terms of this Agreement, and specifications covering the
services.
D. CONTRACTOR agrees that County Administrator or his designated
representatives may visit CONTRACTOR'S facility (ies) periodically to conduct
random evaluations of services during CONTRACTOR'S normal business hours.
E. CONTRACTOR has, and shall maintain throughout the term of this Agreement,
appropriate licenses and approvals required to conduct its business, and that it will
at all times conduct its business activities in a reputable manner. Proof of such
licenses and approvals shall be submitted to COUNTY upon request.
Section 8. NOTICES
Any notice required or permitted under this agreement shall be in writing and hand
delivered or mailed, postage prepaid, to the other party by certified mail, returned receipt
requested, to the following:
To the COUNTY: Maria Fernandez - Gonzalez, Sr. Benefits Administrator
1100 Simonton Street, Suite 2 -268
Key West, Florida 33040
To the CONTRACTOR:
Section 9. RECORDS
CONTRACTOR shall maintain all books, records, and documents directly pertinent to
performance under this Agreement in accordance with generally accepted accounting
principles consistently applied. Each party to this Agreement or their authorized
representatives shall have reasonable and timely access to such records of each other
party to this Agreement for public records purposes during the term of the agreement and
for five years following the termination of this Agreement. If an auditor employed by the
COUNTY or Clerk determines that monies paid to CONTRACTOR pursuant to this
Agreement were spent for purposes not authorized by this Agreement, the
CONTRACTOR shall repay the monies together with interest calculated pursuant to
Section 55.03 of the Florida Statutes, running from the date the monies were paid to
CONTRACTOR.
Section 10. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010
AND 020 -1990
The CONTRACTOR warrants that it has not employed, retained or otherwise had act on
its behalf any former County officer or employee subject to the prohibition of Section 2 of
Ordinance No. 010 -1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 020 -1990. For breach or violation of this provision the COUNTY may, in its
discretion, terminate this agreement without liability and may also, in its discretion, deduct
from the agreement or purchase price, or otherwise recover the full amount of any fee,
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commission, percentage, gift, or consideration paid to the former County officer or
employee.
Section 11. CONVICTED VENDOR
A person or affiliate who has been placed on the convicted vendor list following a
conviction for public entity crime may not submit a bid on a Agreement with a public entity
for the construction or repair of a public building or public work, may not perform work as a
CONTRACTOR, supplier, subcontractor, or CONTRACTOR under Agreement with any
public entity, and may not transact business with any public entity in excess of the
threshold amount provided in Section 287.017 of the Florida Statutes, for the Category
Two for a period of 36 months from the date of being placed on the convicted vendor list.
Section 12. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES
This Agreement shall be governed by and construed in accordance with the laws of the
State of Florida applicable to Agreements made and to be performed entirely in the State.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR agree
that venue shall lie in the appropriate court or before the appropriate administrative body
in Monroe County, Florida.
Section 13. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the application thereof
to any circumstance or person) shall be declared invalid or unenforceable to any extent by
a court of competent jurisdiction, the remaining terms, covenants, conditions and
provisions of this Agreement, shall not be affected thereby; and each remaining term,
covenant, condition and provision of this Agreement shall be valid and shall be
enforceable to the fullest extent permitted by law unless the enforcement of the remaining
terms, covenants, conditions and provisions of this Agreement would prevent the
accomplishment of the original intent of this Agreement. The COUNTY and
CONTRACTOR agree to reform the Agreement to replace any stricken provision with a
valid provision that comes as close as possible to the intent of the stricken provision.
Section 14. ATTORNEY'S FEES AND COSTS
The COUNTY and CONTRACTOR agree that in the event any cause of action or
administrative proceeding is initiated or defended by any party relative to the enforcement
or interpretation of this Agreement, the prevailing party shall be entitled to reasonable
attorney's fees, and court costs, as an award against the non - prevailing party. Mediation
proceedings initiated and conducted pursuant to this Agreement shall be in accordance
with the Florida Rules of Civil Procedure and usual and customary procedures required by
the Circuit Court of Monroe County.
Section 15. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to
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the benefit of the COUNTY and CONTRACTOR and their respective legal representatives,
successors, and assigns.
Section 16. AUTHORITY
Each party represents and warrants to the other that the execution, delivery and
performance of this Agreement have been duly authorized by all necessary County and
corporate action, as required by law.
Section 17. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
COUNTY and CONTRACTOR agree that all disputes and disagreements shall be
attempted to be resolved by meet and confer sessions between representatives of each of
the parties. If no resolution can be agreed upon within 30 days after the first meet and
confer session, then any party shall have the right to seek such relief or remedy as may be
provided by this Agreement or by Florida law. This Agreement shall not be subject to
arbitration.
Section 18. COOPERATION
In the event any administrative or legal proceeding is instituted against either party relating
to the formation, execution, performance, or breach of this Agreement, COUNTY and
CONTRACTOR agree to participate, to the extent required by the other party, in all
proceedings, hearings, processes, meetings, and other activities related to the substance
of this Agreement or provision of the services under this Agreement. COUNTY and
CONTRACTOR specifically agree that no party to this Agreement shall be required to
enter into any arbitration proceedings related to this Agreement.
Section 19. NONDISCRIMINATION
The parties agree that there will be no discrimination against any person, and it is
expressly understood that upon a determination by a court of competent jurisdiction that
discrimination has occurred, this Agreement automatically terminates without any further
action on the part of any party, effective the date of the court order. The parties agree to
comply with all Federal and Florida statutes, and all local ordinances, as applicable,
relating to nondiscrimination. These include but are not limited to: 1) Title VII of the Civil
Rights Act of 1964 (PL 88 -352), which prohibit discrimination in employment on the basis
of race, color, religion, sex, and national origin; 2) Title IX of the Education Amendment of
1972, as amended (20 USC §§ 1681 -1683, and 1685 - 1686), which prohibits discrimination
on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC
§ 794), which prohibits discrimination on the basis of handicaps; 4) The Age
Discrimination Act of 1975, as amended (42 USC §§ 6101 - 6107), which prohibits
discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972
(PL 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; 6) The
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (PL 91 -616), as amended, relating to nondiscrimination on the basis of alcohol
abuse or alcoholism; 7) The Public Health Service Act of 1912, §§ 523 and 527 (42 USC
§§ 690dd -3 and 290ee -3), as amended, relating to confidentiality of alcohol and drug
abuse patent records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC §§ 3601 et
seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing;
9) The Americans with Disabilities Act of 1990 (42 USC §§ 1201), as amended from time
to time, relating to nondiscrimination in employment on the basis of disability; 10) Monroe
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County Code Chapter 13, Article VI, which prohibits discrimination on the basis of race,
color, sex, religion, national origin, ancestry, sexual orientation, gender identity or
expression, familial status or age; and 11) any other nondiscrimination provisions in any
federal or state statutes which may apply to the parties to, or the subject matter of, this
Agreement.
Section 20. COVENANT OF NO INTEREST
COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall
not acquire any interest, which would conflict in any manner or degree with its
performance under this Agreement, and that only interest of each is to perform and
receive benefits as recited in this Agreement.
Section 21. CODE OF ETHICS
COUNTY agrees that officers and employees of the COUNTY recognize and will be
required to comply with the standards of conduct for public officers and employees as
delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or
acceptance of gifts; doing business with one's agency; unauthorized compensation;
misuse of public position, conflicting employment or contractual relationship; and
disclosure or use of certain information.
Section 22. NO SOLICITATION /PAYMENT
The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither
employed nor retained any company or person, other than a bona fide employee working
solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay
any person, company, corporation, individual, or firm, other than a bona fide employee
working solely for it, any fee, commission, percentage, gift, or other consideration
contingent upon or resulting from the award or making of this Agreement. For the breach
or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the
right to terminate this Agreement without liability and, at its discretion, to offset from
monies owed, or otherwise recover, the full amount of such fee, commission, percentage,
gift, or consideration.
Section 23. PUBLIC ACCESS
The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and
inspection of, all documents, papers, letters or other materials in its possession or under
its control subject to the provisions of Chapter 119, Florida Statutes, and made or received
by the COUNTY and CONTRACTOR in conjunction with this Agreement; and the
COUNTY shall have the right to unilaterally cancel this Agreement upon violation of this
provision by CONTRACTOR.
Section 24. NON - WAIVER OF IMMUNITY
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the
COUNTY and the CONTRACTOR in this Agreement and the acquisition of any
commercial liability insurance coverage, self- insurance coverage, or local government
liability insurance pool coverage shall not be deemed a waiver of immunity to the extent of
liability coverage, nor shall any Agreement entered into by the COUNTY be required to
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contain any provision for waiver.
Section 25. PRIVILEGES AND IMMUNITIES
All of the privileges and immunities from liability, exemptions from laws, ordinances, and
rules and pensions and relief, disability, workers' compensation, and other benefits which
apply to the activity of officers, agents, or employees of any public agents or employees of
the COUNTY, when performing their respective functions under this Agreement within the
territorial limits of the COUNTY shall apply to the same degree and extent to the
performance of such functions and duties of such officers, agents, volunteers, or
employees outside the territorial limits of the COUNTY.
Section 26. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non - Delegation of Constitutional or Statutory Duties. This Agreement is not intended to,
nor shall it be construed as, relieving any participating entity from any obligation or
responsibility imposed upon the entity by law except to the extent of actual and timely
performance thereof by any participating entity, in which case the performance may be
offered in satisfaction of the obligation or responsibility. Further, this Agreement is not
intended to, nor shall it be construed as, authorizing the delegation of the constitutional or
statutory duties of the COUNTY, except to the extent permitted by the Florida constitution,
state statute, and case law.
Section 27. NON - RELIANCE BY NON - PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this
Agreement to enforce or attempt to enforce any third -party claim or entitlement to or
benefit of any service or program contemplated hereunder, and the COUNTY and the
CONTRACTOR agree that neither the COUNTY nor the CONTRACTOR or any agent,
officer, or employee of either shall have the authority to inform, counsel, or otherwise
indicate that any particular individual or group of individuals, entity or entities, have
entitlements or benefits under this Agreement separate and apart, inferior to, or superior to
the community in general or for the purposes contemplated in this Agreement.
Section 28. ATTESTATIONS
CONTRACTOR agrees to execute suc h
require, including, but not being limited
Statement, and a Drug -Free Workplac e
Clause, and Non - Collusion Agreement.
documents as the COUNTY may reasonably
to, a Public Entity Crime Statement, an Ethics
Statement, Lobbying and Conflict of Interest
Section 29. NO PERSONAL LIABILITY
No covenant or agreement contained herein shall be deemed to be a covenant or
agreement of any member, officer, agent or employee of Monroe County in his or her
individual capacity, and no member, officer, agent or employee of Monroe County shall be
liable personally on this Agreement or be subject to any personal liability or accountability
by reason of the execution of this Agreement.
Section 30. EXECUTION IN COUNTERPARTS
This Agreement may be executed in any number of counterparts, each of which shall be
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regarded as an original, all of which taken together shall constitute one and the same
instrument and any of the parties hereto may execute this Agreement by signing any such
counterpart.
Section 31. SECTION HEADINGS
Section headings have been inserted in this Agreement as a matter of convenience of
reference only, and it is agreed that such section headings are not a part of this
Agreement and will not be used in the interpretation of any provision of this Agreement.
Section 32. INSURANCE POLICIES
32.1 General Insurance Requirements for Other Contractors and Subcontractors.
As a pre- requisite of the work governed, the CONTRACTOR shall obtain, at his /her own
expense, insurance as specified in any attached schedules, which are made part of this
contract. The CONTRACTOR will ensure that the insurance obtained will extend
protection to all Subcontractors engaged by the CONTRACTOR. As an alternative, the
CONTRACTOR may require all Subcontractors to obtain insurance consistent with the
attached schedules; however CONTRACTOR is solely responsible to ensure that said
insurance is obtained and shall submit proof of insurance to COUNTY. Failure to provide
proof of insurance shall be grounds for termination of this Agreement.
The CONTRACTOR will not be permitted to commence work governed by this contract
until satisfactory evidence of the required insurance has been furnished to the COUNTY
as specified below. Delays in the commencement of work, resulting from the failure of the
CONTRACTOR to provide satisfactory evidence of the required insurance, shall not
extend deadlines specified in this contract and any penalties and failure to perform
assessments shall be imposed as if the work commenced on the specified date and time,
except for the CONTRACTOR's failure to provide satisfactory evidence.
The CONTRACTOR shall maintain the required insurance throughout the entire term of
this contract and any extensions specified in the attached schedules. Failure to comply
with this provision may result in the immediate suspension of all work until the required
insurance has been reinstated or replaced and /or termination of this Agreement and for
damages to the COUNTY. Delays in the completion of work resulting from the failure of
the CONTRACTOR to maintain the required insurance shall not extend deadlines
specified in this contract and any penalties and failure to perform assessments shall be
imposed as if the work had not been suspended, except for the CONTRACTOR's failure to
maintain the required insurance.
The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the
required insurance, either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all
insurance policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non - renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior
notification is given to the County by the insurer.
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The acceptance and /or approval of the Contractor's insurance shall not be construed as
relieving the Contractor from any liability or obligation assumed under this contract or
imposed by law.
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on all policies, except for Workers' Compensation.
32.2 Insurance Requirements For Contract Between County And Contractor
(Note: amounts of coverage are subject to change in final contract)
Prior to the commencement of work governed by this contract, the CONTRACTOR shall
obtain General Liability Insurance. Coverage shall be maintained throughout the life of the
contract and include, as a minimum:
Premises Operations
Bodily Injury Liability
Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy,
its provisions should include coverage for claims filed on or after the effective date of this
contract. In addition, the period for which claims may be reported should extend for a
minimum of twelve (12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional
Insured on all policies issued to satisfy the above requirements.
The Monroe County Board of County Commissioners shall be named as Additional
Insured on all policies issued to satisfy the above requirements.
32.3 Workers' Compensation Insurance Requirements
Prior to commencement of work governed by this contract, the CONTRACTOR shall
obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable
state statutes.
In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of
not less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
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$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business
in the state of Florida.
32.4 Professional Liability Requirements
Recognizing that the work governed by this contract involves the furnishing of advise or
services of a professional nature, the Contractor shall purchase and maintain, throughout
the life of the contract, Professional Liability Insurance which will respond to damages
resulting from any claim arising out of the performance of professional services or any
error or omission of the Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$1,000,000 per occurrence and aggregate
Section 33. INDEMNIFICATION
The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the
COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and
Commissions, Officers, and the Employees, and any other agents, individually and
collectively, from all fines, suits, claims, demands, actions, costs, obligations, attorneys
fees, or liability of any kind arising out of the sole negligent actions of the CONTRACTOR
or substantial and unnecessary delay caused by the willful nonperformance of the
CONTRACTOR and shall be solely responsible and answerable for any and all accidents
or injuries to persons or property arising out of its performance of this contract. The
amount and type of insurance coverage requirements set forth hereunder shall in no way
be construed as limiting the scope of indemnity set forth in this paragraph. Further the
CONTRACTOR agrees to defend and pay all legal costs attendant to acts attributable to
the sole negligent act of the CONTRACTOR.
At all times and for all purposes hereunder, the CONTRACTOR is an independent
contractor and not an employee of the Board of County Commissioners. No statement
contained in this agreement shall be construed so as to find the CONTRACTOR or any of
his /her employees, contractors, servants or agents to be employees of the Board of
County Commissioners for Monroe County. As an independent contractor the
CONTRACTOR shall provide independent, professional judgment and comply with all
federal, state, and local statutes, ordinances, rules and regulations applicable to the
services to be provided.
The CONTRACTOR shall be responsible for the completeness and accuracy of its work,
plan, supporting data, and other documents prepared or compiled under its obligation for
this project, and shall correct at its expense all significant errors or omissions therein
which may be disclosed. The cost of the work necessary to correct those errors
attributable to the CONTRACTOR and any damage incurred by the COUNTY as a result
of additional costs caused by such errors shall be chargeable to the CONTRACTOR. This
provision shall not apply to any maps, official records, contracts, or other data that may be
provided by the COUNTY or other public or semi - public agencies.
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The CONTRACTOR agrees that no charges or claims for damages shall be made by it for
any delays or hindrances attributable to the COUNTY during the progress of any portion of
the services specified in this contract. Such delays or hindrances, if any, shall be
compensated for by the COUNTY by an extension of time for a reasonable period for the
CONTRACTOR to complete the work schedule. Such an agreement shall be made
between the parties.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed
on the day of 2011_
(SEAL)
Attest: DANNY L. KOLHAGE, CLERK
OF MONROE COUNTY, FLORIDA
Deputy Clerk
(CORPORATE SEAL)
ATTEST:
By
BOARD OF COUNTY COMMISSIONERS
by
Mayor /Chairman
(Name of Contractor)
by
Title:
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SECTION THREE: RESPONSE FORMS
RESPOND TO: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
c/o Employee Services
GATO BUILDING, ROOM 2 -213
1100 SIMONTON STREET
KEY WEST, FLORIDA 33040
1 acknowledge receipt of Addenda No. (s):
I have included
• Lobbying and Conflict of Interest Clause
❑
• Local Preference Form
❑
• Non - Collusion Affidavit
❑
• Drug Free Workplace Form
❑
• Public Entity Crime Statement
❑
• Insurance Requirements
❑
In addition, I have included a current copy of the following professional and occupational
licenses:
List all charges for services, inclusive of all travel and other expenses (there will be no
reimbursable expense items):
( Check mark items above, as reminder that they are included
Mailing Address
Signed:
Witness:
(Print Name)
(Title)
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
known to me or has produced
identification) as identification.
Telephone:
Fax:
Date:
(name of affiant). He /She is personally
(type of
NOTARY PUBLIC
My Commission Expires:
-29-
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 010 -1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
(Company)
"...warrants that he /it has not employed, retained or otherwise had act on his /her behalf
any former County officer or employee in violation of Section 2 of Ordinance No. 010 -1990
or any County officer or employee in violation of Section 3 of Ordinance No. 010 -1990.
For breach or violation of this provision the County may, in its discretion, terminate this
Agreement without liability and may also, in its discretion, deduct from the Agreement or
purchase price, or otherwise recover, the full amount of any fee, commission, percentage,
gift, or consideration paid to the former County officer or employee."
(Signature)
Date:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
(name of affiant). He /She is
personally known to me or has produced
(type of identification) as
identification.
NOTARY PUBLIC
My Commission Expires:
-30-
LOCAL PREFERENCE FORM
A. Vendors claiming a local preference according to Ordinance 023 -2009 must complete this form.
Name of Bidder /Responder
Date:
1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax
Collector dated at least one year prior to the notice or request for bid or proposal?
(Please furnish copy. )
2. Does the vendor have a physical business address located within Monroe County from which the
vendor operates or performs business on a day to day basis that is a substantial component of the
goods or services being offered to Monroe County?
List Address:
Telephone Number:
B. Does the vendor /prime contractor intend to subcontract 50% or more of the goods, services or
construction to local businesses meeting the criteria above as to licensing and location?
If yes, please provide:
1. Copy of Receipt of the business tax paid to the Monroe County Tax Collector by the
subcontractor dated at least one year prior to the notice or request for bid or proposal.
2. Subcontractor Address within Monroe County from which the subcontractor operates:
Tel. Number
Name:
Signature and Title of Authorized Signatory for
Bidder /Responder
STATE OF
COUNTY OF
Print
On this day of , 20 , before me, the undersigned notary public, personally
appeared , known to me to be the person whose name is
subscribed above or who produced as identification, and acknowledged
that he /she is the person who executed the above Local Preference Form for the purposes therein
contained.
Notary Public
Print Name
My commission expires: Seal
-31-
NON - COLLUSION AFFIDAVIT
I, of the city of
on my oath, and under penalty of perjury, depose and say that
according to law
1. 1 am of the firm of
the bidder
making the Proposal for the project described in the Request for Proposals
for and that I executed
the said proposal with full authority to do so;
2. The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting
competition, as to any matter relating to such prices with any other bidder or
with any competitor;
3. Unless otherwise required by law, the prices which have been quoted in this
bid have not been knowingly disclosed by the bidder and will not knowingly
be disclosed by the bidder prior to bid opening, directly or indirectly, to any
other bidder or to any competitor; and
4. No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the
purpose of restricting competition; and
5. The statements contained in this affidavit are true and correct, and made
with full knowledge that Monroe County relies upon the truth of the
statements contained in this affidavit in awarding contracts for said project.
(Signature)
Date:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
personally known to me or has produced
identification.
(name of affiant). He /She is
(type of identification) as
NOTARY PUBLIC
My Commission Expires:
-I -
DRUG -FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby
certifies that:
(Name of Business)
1. Publishes a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is prohibited
in the workplace and specifying the actions that will be taken against employees
for violations of such prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the
business' policy of maintaining a drug -free workplace, any available drug
counseling, rehabilitation, and employee assistance programs, and the penalties
that may be imposed upon employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual
services that are under bid a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a
condition of working on the commodities or contractual services that are under bid,
the employee will abide by the terms of the statement and will notify the employer
of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter
893 (Florida Statutes) or of any controlled substance law of the United States or
any state, for a violation occurring in the workplace no later than five (5) days after
such conviction.
5. Imposes a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program if such is available in the employee's
community, or any employee who is so convicted.
6. Makes a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with
the above requirements.
(Signature)
Date:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on (date) by
(name of affiant). He /She is personally
known to me or has produced (type of identification) as
identification.
NOTARY PUBLIC
My Commission Expires:
- 33 -
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following a
conviction for public entity crime may not submit a bid on a contract to provide any goods
or services to a public entity, may not submit a bid on a contract with a public entity for the
construction or repair of a public building or public work, may not submit bids on leases of
real property to public entity, may not be awarded or perform work as a contractor,
supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and
may not transact business with any public entity in excess of the threshold amount
provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36
months from the date of being placed on the convicted vendor list."
I have read the above and state that neither (Respondent's
name) nor any Affiliate has been placed on the convicted vendor list within the last 36
months.
(Signature)
STATE OF:
COUNTY OF:
Date:
Subscribed and sworn to (or affirmed) before me on
(date) by
to me or has produced
identification) as identification.
(type of
NOTARY PUBLIC
(name of affiant). He /She is personally known
My Commission Expires:
-I -
MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION MANUAL
WAIVER OF INSURANCE REQUIREMENTS
There will be times when it will be necessary, or in the best interest of the County, to
deviate from the standard insurance requirements specified within this manual.
Recognizing this potential and acting on the advice of the County Attorney, the Board of
County Commissioners has granted authorization to Risk Management to waive and
modify various insurance provisions.
Specifically excluded from this authorization is the right to waive:
• The County as being named as an Additional Insured
_1
• The Indemnification and Hold Harmless provisions
Waiving of insurance provisions could expose the County to economic loss. For this
reason, every attempt should be made to obtain the standard insurance requirements. If a
waiver or a modification is desired, a Request for Waiver of Insurance Requirement
form should be completed and submitted for consideration with the proposal.
After consideration by Risk Management and if approved, the form will be returned, to the
County Attorney who will submit the Waiver with the other contract documents for
execution by the Clerk of the Courts.
Should Risk Management deny this Waiver Request, the other party may file an appeal
with the County Administrator or the Board of County Commissioners, who retains the final
decision - making authority.
-I -
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of
Insurance Requirements, be waived or modified on the following contract:
Contractor:
Contract for:
Address of Contractor:
Phone:
Scope of Work:
Reason for Waiver
Policies Waiver
will apply to:
Signature of Contractor:
Approved Not Approved
Risk Management:
Date:
County Administrator appeal:
Approved Not Approved
Date:
Board of County Commissioners appeal:
Approved
Not Approved
Meeting Date:
-I -
INSURANCE REQUIREMENTS FOR SUBMITTING PROPOSALS
Worker's Compensation $ 100,000 Bodily Injury by Acc.
$ 500,000 Bodily Inj. by Disease, policy Imts
$ 100,000 Bodily Inj. by Disease, each emp.
General Liability, including $ 300,000 Combined Single Limit
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
Professional Liability Insurance
Professional liability including errors $1,000,000 per Occurrence
and omissions
The Monroe County Board of County Commissioners shall be named as Additional
insured on all policies issued to satisfy the above requirements except Workers'
Compensation and Professional Liability insurance.
-I -
ATTACHMENT A
SCOPE OF SERVICES
SPECIFICATIONS
The scope of services to be provided may include, but are not limited to, the following:
Instructions: Check the applicable box for each service offered. Only provide
explanations if you cannot comply fully with the requested service. Include this
section under TAB 3 in your Proposal.
CLAIMS ADMINISTRATION
Yes
No
Comply with specified
Service
Can
Cannot
Deviations
Comply
Comply
Duplicate and administer
current benefits.
Administer in- network and
out of network benefits.
Make timely and accurate
claims payments to
vendors.
Provide network
management services with
in house staff
Provide billing & eligibility
services to MCBCC
Accept enrollment via paper
or electronic files
Integrate Large Claim
Management, Case
Management, and Disease
Management services to
provide seamless and
effective care and cost
management services to
the County and its
Participants.
Share (accept and
distribute) claims data with
Case Management,
Disease Management, PBM
Wellness, and Stop Loss
vendors, as appropriate.
Provide toll free customer
service number for
employees and
administrative staff.
Provide monthly detailed
claims reports to the
County and the consultant
electronically.
Report potential large
claims with sufficient detail
to file specific and
aggregate stop loss claims,
as needed.
Prepare plan document for
MCBCC approval, in a
timely manner.
Print & distribute plan
booklets to plan
p articipants.
Participate in onsite
meetings at MCBCC
locations to review plan
results, as needed.
Assist with open enrollment
meetings and activities as
required.
Ensure plans are
administered in compliance
with applicable state and
federal regulations.
Adjudicate claims in
accordance with plan
p rovisions.
Provide appropriate reports
to assist with mandated
State and Federal filings.
Provide coordination of
benefits.
Manage Subrogation and
Right of Recovery plan
p rovisions.
Provide a 24 hour nurseline
for participants use.
Provide rate action
information at least 120
days in advance.
All charges for any service
or optional service must be
clearly outlined in the
p ricing Attachment.
Provide performance
g uarantees.
Certify at least annually that
all staff members,
independent contractors,
subcontracted work, if any,
all service providers it uses,
engages or manages,
comply with Health
Insurance Portability and
Accountability Act (HIPAA)
p rivacy and security rules.
UTILIZATION REVIEW, LARGE CASE MANAGEMENT, DISEASE MANAGEMENT
(If your proposal is a standalone proposal for the above services, please indicate how
you are able to integrate /coordinate with the claims administrator(s) in the "Comply
with Deviations" column
Service
Can
Cannot
Can comply with
Comply
C I
specified deviations.
Coordinate with Claims
Comply
Comply
Administrator.
Conduct preadmission
certifications
Provide medical case
management
Provide prior authorization
of specific procedures, such
as advanced imaging (MRI,
CAT scans, PT, OT,
Speech Therapy, Home
Health, etc.
Provide outreach to
members with targeted
conditions or risk factors.
Provide reporting to
MCBCC on LCM and DM
activities to assist in plan
management.
Provide rate action
information at least 120
days in advance.
All charges for any service
or optional service must be
clearly outlined in the
p ricing Attachment.
NETWORK MANAGEMENT
(If your proposal is a standalone proposal for the above services, please indicate how
you are able to integrate /coordinate with the claims administrator(s) in the "Comply
with Deviations" column)
Service
Yes
No
Comply with specified
Can
Cannot
deviations
Comply
Comply
Solicit, screen, evaluate
credentials, and approve
providers to participate in
the network.
Secure discounts from
network providers to enable
MCBCC to achieve plan
savings through effective
network contracting.
Monitor and manage
networks to ensure
Yes,
No
Comply with Specified
sufficient coverage for all
Can
Cannot
Deviations
medical services.
Comply
Comply
Provide medical provider
directories to MCBCC plan
p articipants.
Ensure emergency care is
available for all MCBCC
Medical Plan participants at
in- network benefits.
Collaborate with MCBCC to
ensure continued network
satisfaction.
Ensure appropriate
transition of care to
MCBCC plan participants
as needed.
Provide rate action
information at least 120
days in advance.
All charges for any service
or optional service must be
clearly outlined in the
p ricing Attachment.
PHARMACY BENEFIT MANAGEMENT
(If your proposal is a standalone proposal for the above services, please indicate how
you are able to integrate /coordinate with the claims administrator(s) in the "Comply
with Deviations" column)
Yes,
No
Comply with Specified
Service
Can
Cannot
Deviations
Comply
Comply
Ensure adequate access to
pharmacy network
Provide timely and accurate
payment of appropriate
claims as provided for in
the plan document.
Ensure reporting is
provided to Claims
Administrator to ensure
appropriate DM, LCM, and
Care Coordination is
p ossible.
Provide timely and clear
communication to MCBCC
and its participants for any
changes to the formulary or
network
Provide claim reporting to
MCBCC in sufficient detail
to ensure proper funding for
claims payment, plan
funding decisions & stop
Can
Can comply with
loss claims filings.
Comply
Cannot
specified deviations.
Ad_hoc reports must be
C I
provided within a
reasonable time frame i.e.
within one week for simple
requests.
Online reporting should be
available for both MCBCC
and GBS, at the client's
request.
Provide rate action
information at least 120
days in advance.
All charges for any service
or optional service must be
clearly outlined in the
p ricing Attachment.
WELLNESS
(If your proposal is a standalone proposal for the above services, please indicate how
you are able to integrate /coordinate with the claims administrator(s) in the "Comply
with Deviations" column)
Can
Can comply with
Service
Comply
Cannot
specified deviations.
C I
Provide Health Risk
Assessments
Provide Biometric
Screening for all plan
p articipants
Provide one -on —one health
coachin
Provide onsite staff to drive
the development of
Wellness Initiatives.
Design, develop, and direct
Health Fairs for plan
p articipants
Design, develop and direct
employee wellness
activities — at least quarterl
Provide outreach to
employees with critical
scores on the
HRA/Biometric Screenings
Provide the results of
Biometric screenings to the
Claims Administrator /
Disease Management
vendor
Provide rate action
information at least 120
days in advance.
All charges for any service
or optional service must be
clearly outlined in the
p ricing Attachment.
STOP LOSS INSURANCE
Optional Fully insured Medical Benefit Plan - Complete the Scope of Services charts
listed above for your fully insured proposals.
If a fully insured medical benefit plan is proposed, the Proposer must provide all the services
currently included in the self- insured medical benefit plan including direct submission of
claims, pre - certification of listed medical procedures, Utilization Review, Large Case
Management, Disease Management, employee service hotline, claim reporting , Network
Management, Pharmacy Benefit Management, assistance with plan design and changes,
preparation of ID cards and plan booklets, assistance with and attendance at open
enrollment employee meetings and other requested services. The County also desires a
fully functional Wellness Program. Complete the Scope of Services charts listed above
for your fully insured proposals.
The features of the health plan currently offered by the County to plan participants is outlined
in Attachment B to this RFP. Initially, please propose benefit plans that duplicate the current
benefit levels as closely as possible, and then propose your other plan benefit options.
Rates are requested for a three year contract term with the second and third year rates
subject to maximum not -to- exceed amounts. All of the required information in this RFP
applies to fully- insured proposals
Yes
No
Comply with Specified
Service
Can
Cannot
Deviations
Comply
Comply
Utilize MCBCC Medical
Plan document as basis for
claims administration of SL
claims.
Provide prompt
reimbursement of specific
and aggregate claims.
Provide estimated renewal
120 days in advance of
renewal.
Provide firm renewal rates
45 days in advance of
renewal.
Guarantee no lasers of
individuals on renewal
except at the specific
request of MCBCC.
All charges for any service
or optional service must be
clearly outlined in the
p ricing Attachment.
Optional Fully insured Medical Benefit Plan - Complete the Scope of Services charts
listed above for your fully insured proposals.
If a fully insured medical benefit plan is proposed, the Proposer must provide all the services
currently included in the self- insured medical benefit plan including direct submission of
claims, pre - certification of listed medical procedures, Utilization Review, Large Case
Management, Disease Management, employee service hotline, claim reporting , Network
Management, Pharmacy Benefit Management, assistance with plan design and changes,
preparation of ID cards and plan booklets, assistance with and attendance at open
enrollment employee meetings and other requested services. The County also desires a
fully functional Wellness Program. Complete the Scope of Services charts listed above
for your fully insured proposals.
The features of the health plan currently offered by the County to plan participants is outlined
in Attachment B to this RFP. Initially, please propose benefit plans that duplicate the current
benefit levels as closely as possible, and then propose your other plan benefit options.
Rates are requested for a three year contract term with the second and third year rates
subject to maximum not -to- exceed amounts. All of the required information in this RFP
applies to fully- insured proposals
Monroe County Group Health Plan Document
Board of County Commissioners
Clerk of the Circuit Court
Land Authority
Property Appraiser
Sheriff's Office
Supervisor of Elections
Tax Collector
EFFECTIVE JANUARY 1, 2010
The Monroe County Group Health Plan (the Plan) was established 6 the Monroe County board of County
Commissioners (bOCC). The Plan includes the E_ligi6le Employees, E Retirees and E
Dependents of the following Monroe County Employers: the 15OCC, Clerk of the Circuit Court, Land
Authority, Property. Appraiser, 5herifF's Office, Supervisor of Elections and Tax Collector. The Plan's
Claims Administrator is Wells Fargo Third Party Administrator (Wells Fargo TPA) and Monroe County
board of County Commissioners (bOCC) is the Plan Administrator.
The Plan provides a combination of three preferred provider organization networks (PPO) and traditional
benefits programs: Keys Physician - Hospital Alliance, or KPHA, in Monroe County; Dimension Plus in Miami -
Dade, broward, Palm beach and Monroe Counties; and the MultiPlan /FHCS Network everywhere else in
the nation. Underthe Plan, Covered Plan Participants may receive greater benefits when obtaining Covered
Services from a PPO network provider, however, benefits are provided for Covered Services when rendered 6,
a non -FPO network provider, although generally at higher prices in non - emergency cases. Covered Plan
Participants are free to select any health care Provider, however, benefits under the Plan will pay for Covered
Services rendered by a Provider who is recognized for payment 6, the Monroe County Group health Plan
Document at the time the Covered Plan Participant receives health Care Services.
To find out about a health care Provider's participation status, a Covered Plan Participant may review any of the
Plan's Preferred Provider Organization Network Directories in effect 6 calling the benefits Office at 305 -
292-4579 orthe Keys Physician - hospital Alliance (KPHA) at 305-294-4599 or 1-800-+00-098+. Covered
Plan Participants can also visit ourwe6 -site at
htti2: / /monroecofl.virtualtownhall .net /Pages /MonroeCoFl Group Insurance /index
Please carefully review the Schedule of benefits which is a part of the Monroe County Group Health Plan
Document for a detailed list off inancial responsibilities. This is important because financial responsibilities,
includin ang aj2plica6le Deductibles and Coinsurance responsibilities, will vary{ depending pon the Providers
choosen.
This Monroe County Group Health Plan Document supersedes all other Monroe County Group Health Plan
Documents and amendments and shall 6e the sole document used in determining benefits for which Covered Plan
Participants are eligible. The Monroe County Group Health Plan Document may 6e amended from time to time
6, the Monroe County board of County Commissioners, in its sole discretion, to reflect changes in benefits,
eligibility requirements, plan participant contributions, or changes in the law. It is not in lieu of and does not affect
any requirements for coverage 6, Workers' Compensation.
It is the responsibility of each Covered Plan Participant to understand their benefits, rights and obligations
under the Monroe County Group Health Plan Document. For questions or language clarification contact the
benefits Office at 305-292-4579•
GENERAL PLAN INFORMATION
TYPE OF ADMINISTRATION
The Plan is a self - funded employee group health plan. Claims administration is provided through a Third Party
Claims Administrator and prescription coverage through a Pharmacy Benefits Manager. The funding for these
benefits is derived from the funds of the Employers and contributions made by the Covered Plan Participants.
PLAN NAME: MONROE COUNTY GROUP HEALTH PLAN
PLAN NUMBER: 5830
TAX ID NUMBER: 59- 6000749
PLAN REVISION DATE: 01/01/10
PLAN YEAR ENDS: 12/31
EMPLOYERS: Monroe County Board of County Commissioners
Clerk of the Circuit Court
Land Authority
Property Appraiser
Tax Collector
Supervisor of Elections
Monroe County Sheriffs Office
PLAN ADMINISTRATOR: Monroe County Board of County Commissioners
Benefits Office
1100 Simonton Street, Suite 2 -268
Key West, FL 33040
Lower Keys: (305) 292 -4446
Middle Keys: (305) 743 -0079
Upper Keys: (305) 852 -1469
CLAIMS ADMINISTRATOR: Wells Fargo Third Party Administrators, Inc. (TPA)
P. O. Box 3262
Charleston, WV 25332
(800) 624 -8605
PHARMACY BENEFIT MANAGER:
Walgreens Health Initiatives, Inc.
P. O. Box 545
Deerfield, IL 60015
Customer Care Center: 1- 800 - 207 -2568
World Wide Web: www.mywhi.com
CERTIFICATION: Keys Physician - Hospital Alliance (KPHA)
P. O. Box 9107
Key West, FL 33041
(305) 294 -4599 or (800) 400 -0984
TABLE OF CONTENTS
SECTION 1 - SCHEDULE OF BENEFITS ................................................................... ............................... 1 - 1
SECTION 2 - COVERED PLAN PARTICIPANT'S FINANCIAL OBLIGATIONS ............ ............................... 2-1
SECTION 3 - HEALTH CARE PROVIDER ALTERNATIVES AND REIMBURSEMENT RULES .................... 3-1
SECTION 4 - PRE-EXISTING CONDITIONS EXCLUSION PERIOD ............................. ............................... 4-1
SECTION 5 - BENEFIT UTILIZATION MANAGEMENT /UTILIZATION REVIEW PROGRAMS ..................... 5-1
SECTION 6 - MEDICAL NECESSITY .......................................................................... ............................... 6-1
SECTION 7 - COVERED SERVICES .......................................................................... ............................... 7 - 1
SECTION 8 - GENERAL EXCLUSIONS ..................................................................... ............................... 8_1
SECTION 9 - ELIGIBILITY FOR COVERAGE .............................................................. ............................... 9-1
SECTION 10 - ENROLLMENT & EFFECTIVE DATE OF COVERAGE ....................... ............................... 10-1
SECTION 1 1 - TERMINATION OF COVERAGE ......................................................... ............................... 1 1- 1
SECTION 12 - CONTINUING COVERAGE UNDER COBRA ................................... ............................... 1 2 - 1
SECTION 13 - CONVERSION PRIVILEGE ................................................................ ............................... 1 3- 1
SECTION 14 - EXTENSION OF BENEFITS ............................................................... ............................... 1 4- 1
SECTION 15 - MEDICARE COVERAGE /MEDICARE SECONDARY PAYER PROVISIONS ...................... 1 5 - 1
SECTION 16 - COORDINATION OF BENEFITS ........................................................ ............................... 1 6- 1
SECTION 17 - SUBROGATION, RIGHT OF REIMBURSEMENT & EQUITABLE LIEN ............................... 1 7 - 1
SECTION 18 - CLAIMS PROCESSING ..................................................................... ............................... 1 8- 1
SECTION 19 - GENERAL PROVISIONS ................................................................... ............................... 1 9- 1
SECTION 20 - HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) ....................... 20-1
SECTION 21 - DEFINITIONS .................................................................................... ............................... 21 - 1
Table of Contents
SECTION 'I - SCHEDULE OF BENEFITS
Covered Plan Participants should carefully review this Schedule of Benefits. The Plan provides coverage for adult
wellness services without having to satisfy a Calendar Year Deductible requirement. Financial responsibilities,
including any applicable Deductible and Coinsurance responsibilities will vary depending upon the Providers
chosen by the Covered Plan Participant.
A. DEDUCTIBLE AND COINSURANCE AMOUNTS
Benefit Description
In- Network
Out -of- Network
Individual Calendar Year Deductible CYD
$300
$300
Family Calendar Year Deductible CYD
$600
$600
Hospital Per Admission Deductible (PAD)
$150
5150
Pediatrics
In addition to the CYD
In addition to the CYD
Office Services Rendered by:
and applic able Coinsurance
and applicable Coinsurance
Emergency Room Per Visit Deductible
$75
$75
2. Other health care professionals licensed to
In addition to the CYD
In addition to the CYD and
p erform such services.
and applic able Coinsurance
plicable Coinsurance
Coinsurance Percentage Payable By The Plan Per
75%
45%
Calendar Year
of Allowed Amount
of Allowed Amount
Coinsurance Payable by The Plan for Ambulance Services
75%
75%
Benefits Office at 305 - 292 -4579 or 305 - 292 -4446 for assistance.
of the Allowed Amount
of the Allowed Amount
Individual Coinsurance Responsibility Limit Per Calendar
$7,700
$7,700
Year
Note: Coinsurance Responsibility Limits do not include the CYD amount, the Hospital PAD amount, the
Emergency Room Per Visit Deductible amount, any benefit penalty reduction, non - covered charges or any
charges in excess of the Allowed Amount.
B. OFFICE SERVICES
Benefit Description
In- Network
Out -of- Network
Office Services Rendered by Family Physicians with the
75%
45%
following Specialties:
of Allowed Amount
of Allowed Amount
Family Practice, General Practice, Internal Medicine, and
Pediatrics
Office Services Rendered by:
75%
45%
1. Physicians other than Family Physicians; and
of Allowed Amount
of Allowed Amount
2. Other health care professionals licensed to
p erform such services.
Durable Medical Equipment, Prosthetics and Orthotics
75%
45%
of Allowed Amount
of Allowed Amount
Note: A Covered Plan Participant should verify a Provider's participation status prior to receiving Health Care
Services. To verify a Provider's participation status just access any one of our three PPO Networks through our
web site at http : / /monroecofl.virtualtownhall .net /Pages /MonroeCoFl Group Insurance /index or contact the
Benefits Office at 305 - 292 -4579 or 305 - 292 -4446 for assistance.
Schedule of Benefits 1 - 1
C. BENEFIT MAXIMUMS
Accumulated Total Lifetime Maximum Benefit Per Covered Participant ........... .....................$1,000,000
(includes medical care services & pharmaceuticals)
Adult Wellness Per Covered Plan Participant Every 12 Months Age 40 and over .. ............................... $400
Adult Wellness Per Covered Plan Participant Every 24 Months Age 39 and under . ............................... $400
Covered Services as described below for an adult. For purposes of this benefit an adult is 17 years or older.
Adult Wellness Services include:
1. annual physical or gynecological exam; and
2. related wellness services including, but not limited to pap smears; Prostate Specific Antigen (PSA), x -rays,
laboratory services, and immunizations. Routine vision and hearing examinations and screenings are not
covered.
Note: The wellness services above are not subject to the CYD. Any charges in excess of the maximum allowed by
The Plan of $400 are the responsibility of the Covered Plan Participant and do not count toward the Individual
Coinsurance Responsibility Limit Per Calendar Year. All wellness claims must have a routine diagnosis to be
covered under this benefit.
Autism Spectrum Disorder Per Covered Plan Participant Per Calendar Year/Lifetime ........... $36,000 /$200,000
Enteral Formulas Per Covered Plan Participant Per Calendar Year ........................... ..................$2,700
Home Health Care Per Covered Plan Participant Per Calendar Year ................... .........................$7,500
Hospice (Combined Inpatient, Outpatient and Home)
Per Covered Plan Participant Per Lifetime ................................ ............................... .........Unlimited
Outpatient Cardiac, Occupational, Physical, Speech Therapies
Per Covered Plan Participant Per Calendar Year .......................... ............................... ............$5,000
Outpatient Private Duty Nursing Visits Per Covered Plan Participant Per Calendar Year ........................40
Skilled Nursing Facility Days Per Covered Plan Participant Per Calendar Year ...... ......................Unlimited
Spinal Manipulations and Massage Therapies Per Covered Plan Participant Per Calendar Year ...... ... $1,000
TMJ Services Per Covered Plan Participant Per Lifetime .................. .............. .........................$2,000
D. ADMISSION CERTIFICATION REQUIREMENTS
All Hospital admissions must be certified. Any non - certified admissions are subject to a 30% benefit penalty
reduction. The Covered Plan Participant is responsible for obtaining certification for the admission from the Keys
Physician - Hospital Alliance (KPHA) and for any applicable benefit reduction for failure to obtain such certification.
Schedule of Benefits 1-2
E. PRESCRIPTION DRUG PROGRAM
Walgreens Health Initiatives, Inc. (WHI) is the Pharmacy Benefits Manager of the pharmacy drug program for the
Plan.
Copayments
The copayment is applied to each covered pharmacy drug, mail order or Advantage 90 drug charge and is shown in
the Schedule of Benefits. The copayment amount is not a covered charge under the medical plan. Any one
pharmacy prescription is limited to a continuous 30 -day supply. Any one mail order or Advantage 90 prescription is
limited to a continuous 90 -day supply. A continuous day supply is defined as the amount of medication a person
may be anticipated to require within a contiguous 30 or 90 -day period. A medication prescribed "as needed" or not
specifying a daily dosage may be dispensed (with physician approval) in a lesser quantity than daily dosing.
Walgreens Health Initiatives (WHI), Monroe County's Pharmacy Benefit Manager (PBM) works with Monroe
County to ensure that prescription medications are dispensed in an effective and cost - efficient manner. To this end
WHI may:
• Automatically substitute an FDA - approved generic drug for a brand name or formulary drug, unless the
prescribing Physician has noted "Dispense As Written" AND "Medically Necessary" on the prescription
(the Physician will be contacted to verify). The Plan will require the Covered Plan Participant to patio 100%
of the cost of the medication;
• Contact the Physician for permission to substitute a therapeutically equivalent (by FDA guidelines) drug;
• Contact the Physician to re- prescribe if prescribed quantities that do not fall within Plan's day supply
guidelines.
If a drug is purchased from a non - participating pharmacy, or a participating pharmacy when the Covered Plan
Participant's ID card is not used, a Member Prescription Reimbursement Claim Form must be completed and
submitted to WHI for reimbursement to the Covered Plan Participant.
Covered Plan Participant Cost
When a Covered Plan Participant's covered prescriptions are filled under this Program, the Covered Plan
Participant shares a portion of the cost; the Plan pays for the rest. Covered Plan Participant's costs for the program
are as follows:
Retail Pharmacy (short -term medications):
Up to 30 -day supply Generic: $ 10.00
Preferred Brand: $ 25.00
Non - Preferred Brand: $ 70.00
Advantage 90
*Retail Pharmacy (long -term medications):
90 -day supply Generic: $ 25.00
Preferred Brand: $ 62.50
Non - Preferred Brand: $175.00
Mail Service (long -term medications):
Up to 90 -day supply Generic: $ 25.00
Preferred Brand: $ 62.50
Non - Preferred Brand: $175.00
Schedule of Benefits 1-3
It is standard pharmacy practice (and in some states, it is even required by law) to substitute generic equivalents for
brand -name drugs whenever possible.
When a Covered Plan Participant uses the mail service or participating retail pharmacy, the Covered Plan
Participant will receive generic substitutes whenever available and allowable.
Under the Plan's Mandatory Generic Drug Program, whenever a brand -name drug is dispensed when a generic
substitute is available and allowable, the Covered Plan Participant will be responsible for 100% of the cost of
the drug.
NOTE: Should a prescribing Physician write on a prescription "Dispense As Written" and "Medically
Necessary" so the brand -name drug will be dispensed, WHI will contact the Physician to verify.
Clinical Prior Authorization Program
Certain prescriptions require "clinical prior authorization," or approval from the Plan, before they will be covered.
The categories /medications that require clinical prior authorization may include, but are not limited to: Acne
(topical -cover through age 24); Actiq (limit 42 units per 365 -day supply); ADHD /Narcolepsy (cover through age
19), Anabolic Steroids (all types), Butorphanol (after two -2.5 ml bottles per 25 -day supply), Byetta; Contraceptives;
Fentora, Impotency (maximum 8 qty.), Insomnia (limit 30 qty. per 30 -day supply); Migraine (after 8 injectable, 8
nasal or 18 oral per 25 -day supply), OxyContin (daily average limit of 3) and Symlin.
To confirm whether clinical prior authorization is needed or requested, call 1- 877 - 665 -6609. Please have available
the name of medication, Physician's name, phone (and fax number, if available), member ID number and group
number on the WHI Identification Card.
Step Care
The clinical prior authorization program generally requires utilization of an effective first -line agent before other
alternative therapies may be covered. The Plan requires this program to be in place for the following categories:
COX -2 Inhibitors; Dipeptidyl Peptidase -4 Inhibitors; Oral Bisphosphomate and Proton Pump Inhibitors (OTC
Prilosec). For more information call 1- 877 - 665 -6609.
Covered Drugs
• Compound prescription containing at least one legend ingredient
• Federal legend drugs (that is, drugs that federal law prohibits dispensing with a prescription)
• Insulin and other diabetic supplies when prescribed by a Physician.
Drugs Not Covered
• Contraceptives
• Dietary Drugs
• Food and /or food supplements
• Fertility drugs
• Infertility drugs
• Over -the- counter (OTC) items
• Retin -A
• Rogaine (or similar products)
Schedule of Benefits 1-4
• Smoking deterrents
• Vitamins
This is a partiallisting of covered and non - covered drugs. Certain prescriptions may require physician confirmation
of medical necessity. For specific drug inquiries, contact the WHI Customer Care Center at 1- 800 - 207 -2568.
Appeal of Adverse Drug Coverage Determination
Covered Plan Participant's can appeal an adverse drug coverage determination by contacting the Benefits Office at
305 - 292 -4579 to initiate the appeal process.
Participating Pharmacies
There are over 62,000 participating pharmacies to choose from. Below are just some of the local pharmacies who
participate in our nationwide retail network.
• Albertsons*
• Dennis Pharmacy*
• Medicine Shoppe
• CVS*
• Publix*
• Walgreens*
• Winn - Dixie*
*pharmacies participating in the 90 -day retail program
Note: Participating pharmacies are subject to change without notice
Preferred Medication List — Medication Categories Guide
The Preferred Medication List (PML) was developed by Walgreens Health Initiatives under the direction of a
committee of doctors and pharmacists. All medications on this list are preferred by the Plan.
Covered Plan Participant's can make the most of their pharmacy benefit plan and control their prescription
medication costs by using this Preferred Medication List. Whenever possible, have your doctor consult this guide
for lowest -cost brand -name and generic medications available for your therapy. All medications on the PML have
been approved by the FDA.
Please note: The PML is subject to change without notice.
For a Copy or to View the Preferred Medication List — Please visit www.mywhi.com
Questions about the Preferred Medication List — Please call the Walgreens Customer Care Center 1- 800 -207-
2568.
Schedule of Benefits 1-5
SECTION 2 - COVERED PLAN PARTICIPANT'S FINANCIAL OBLIGATIONS
This section sets out a Covered Plan Participant's financial obligations under the Monroe County Group Health
Plan Document. Important information concerning these financial obligations is set forth in the Schedule of
Benefits.
Calendar Year Deductible Requirement
Individual Calendar Year Deductible Requirement: This requirement, when applicable, must be satisfied by
each Covered Plan Participant each Calendar Year before any payment will be made by the Plan. Only
those charges indicated on claims received for Covered Services will be credited toward the Individual
Calendar Year Deductible requirement and only up to the applicable Allowed Amount.
2. Family Calendar Year Deductible: Once the Covered Employee's family has reached such limit, no Covered
Plan Participant in that family will have any additional Calendar Year Deductible responsibility for the
remainder of that Calendar Year. The maximum amount that any Covered Plan Participant in the family
can contribute toward the Family Calendar Year Deductible requirement is the amount applied toward the
Individual Calendar Year Deductible amount.
Note: In situations where the Benefits Office is notified by a Covered Employee that their spouse or Registered
Domestic Partner is also a Covered Employee of an Employer and one has elected family coverage only two
Individual Calendar Year Deductibles are required to satisfy the Family Calendar Year Deductible for both Covered
Employees.
Hospital Per Admission Deductible
The Hospital Per Admission Deductible must be satisfied by each Covered Plan Participant, for each Hospital
admission, before any payment will be made by The Plan for inpatient Health Care Services. The Hospital Per
Admission Deductible applies regardless of the reason for the admission, is in addition to the Calendar Year
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 is set forth in the Schedule of Benefits. The Emergency Room Per
Visit Deductible applies regardless of the reason for the visit, is in addition to the Calendar Year 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.
Coinsurance Responsibility
After the Covered Plan Participant has satisfied the applicable Deductible responsibility, claims for Covered
Services will be paid by the Plan at the Coinsurance percentage of the applicable Allowed Amount as set forth in
the Schedule of Benefits. The unpaid percentage of the Allowed Amount (for in- network services), or the unpaid
percentage of the Allowed Amount plus any additional amount charged by the Provider beyond the Allowed
Amount (for out -of- network services), is the Covered Plan Participant's Coinsurance responsibility.
I. Coinsurance Responsibility Limit /Maximum Out -of- Pocket Coinsurance Amount
a. Individual Coinsurance Responsibility Limit: Once a Covered Plan Participant has reached the
Individual Coinsurance responsibility limit amount as set forth in the Schedule of Benefits, the
Covered Plan Participant's Financial Obligations 2-1
Covered Plan Participant will have no additional Coinsurance responsibility for the remainder of the
Calendar Year and payment for Covered Services will be at 100 percent of the Allowed Amount.
Note: The Individual or Family Calendar Year Deductible, Hospital Per Admission Deductible, Emergency Room
Per Visit Deductible, any benefit penalty reduction, non - covered charges and any charges in excess of the Allowed
Amount are in addition to the Coinsurance Responsibility Limit.
Additional Financial Responsibilities
In addition to the financial obligations set forth above, Covered Plan Participants are also responsible for:
1. expenses incurred for non - Covered Services;
2. charges in excess of any maximum benefit limitation set forth in the Schedule of Benefits (e.g., the lifetime
maximum and Calendar Year maximums);
3. charges in excess of the applicable Allowed Amount on non - emergent use of out -of- network Providers; and
4. any benefit reduction (e.g., benefit penalties resulting from a Covered Plan Participant's failure to comply
with any Benefit Utilization Management/ Utilization Review Program requirements, non - emergent
utilization of out -of- network providers).
Covered Plan Participant's Financial Obligations 2-2
SECTION 3 - HEALTH CARE PROVIDER NETWORKS
& REIMBURSEMENT RULES
Introduction
Covered Plan Participants have access to three Preferred Provider Organization (PPO) Networks under the Plan.
• Keys Physician - Hospital Alliance (305) 294 -4599 or (800) 400 -0984 (Monroe County)
• Dimension Plus (800) 483 -4992 or www.dimensionhealth.com (Miami -Dade, Broward,Palm Beach &
Monroe Counties)
• Multiplan /PHCS Network (800) 557 -6794 or www.multiplan.com (Nationwide)
Covered Plan Participants are free to obtain services from any health care Provider of their choice, including PPO
Providers or health care Providers who do not want to participate in any of our PPO Networks. The
reimbursement rules for Covered Services vary, as explained below, depending on the health care Provider selected
by a Covered Plan Participant to provide Health Care Services.
To find out about a health care Provider's participation status, a Covered Plan Participant can review the PPO
Provider Directories in effect by:
• accessing the Network website (see addresses above);
• accessing the County website at
http : / /monroecofl.virtualtownhall .net /Pages /MonroeCoFl Group Insurance /index
• calling the Benefits Office at 305 - 292 -4446 or 305 - 292 -4579; or
• calling the Provider's office directly.
It is the Covered Plan Participant's sole responsibility to select a Provider when obtaining Health Care
Services and to verify such Provider's participation status, if any, at the time the Health Care Services are
rendered. Please note that certain categories of PPO Providers may not be available in all geographic
regions. This includes anesthesiologists, radiologists, pathologists, specialists, and emergency room
physicians. The Plan will pay for Covered Services rendered by any Physician listed above at the In-
Network benefit level on a case -by -case basis. If Non - Emergency Covered Services were obtained from a
Physician who is not a PPO Provider the Out -of- Network benefit level will apply (30% penalty on all
related charges). Covered Plan Participants will be responsible for this 30 percent penalty in addition to
any Covered Service Charges over the Allowed Amount.
This penalty is the Covered Plan Participant's responsibility and is in addition to all applicable obligations
and limitations under the Monroe County Group Health Plan Document (e.g., the Deductible and
Coinsurance requirements). This penalty amount will not be applied towards the Coinsurance
requirement limits (e.g., the Individual Coinsurance requirement limit) under the Plan.
When a Covered Plan Participant receives Health Care Services from a PPO Provider, the Plan's payment of
expenses for those services which are Covered Services (as defined in the Monroe County Group Health Plan
Document) will be at the Coinsurance percentage set forth in the Schedule of Benefits based on the Allowed
Amount for such services. The Covered Plan Participant's financial responsibility includes:
1. the payment of any applicable Deductible(s) or Coinsurance requirements;
2. the payment of expenses which are not covered, limited or excluded;
3. the payment of any expenses in excess of any benefit maximum limitations; and
4. the payment of any applicable benefit reductions or penalties.
Health Care Provider Networks & Reimbursement Rules 3-1
SECTION 4 - PREEXISTING CONDITIONS EXCLUSION PERIOD
Introduction
Covered Plan Participants when initially enrolled in the Plan will be subject to a Pre - existing Condition
exclusionary period, except newborn or adopted dependents who are properly enrolled. A Covered Plan
Participant with Creditable Coverage in effect for a continuous period of 12 months or longer prior to initial
enrollment will not be subject to a Pre - existing Condition exclusionary period.
Definitions
The following definitions will be referred to for the purpose of this Pre - existing Conditions Exclusion Period
section:
Genetic Information means information about genes, gene products, and inherited characteristics that may derive
from the individual or a family member. This includes information regarding carrier status and information derived
from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations,
family histories, and direct analysis of genes or chromosomes.
Pre - existing Condition means any Condition related to a physical or mental Condition regardless of the cause of
the Condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six -
month period immediately preceding:
1. the first day of the Covered Plan Participant's Waiting Period for Initial Enrollees; or
2. the Covered Plan Participant's Effective Date of coverage under the Monroe County Group Health Plan
Document for special and annual enrollees.
The Pre - existing Condition exclusionary period does not apply to:
i. pregnancy;
2. a newborn child or an adopted newborn child;
3. an adopted child who is covered under Creditable Coverage;
4. Genetic Information in the absence of a diagnosis of the Condition;
5. routine follow -up care of breast cancer after the person was determined to be free of breast cancer.
General
If there is a break in coverage of 63 days or more, no credit will be given for prior Creditable Coverage.
Prior health insurers and /or group health plans are required to provide a certification of Creditable Coverage to the
Covered Plan Participant upon termination of his or her coverage.
There is no coverage under the Monroe County Group Health Plan Document to treat a Pre - existing Condition, or
Conditions arising from a Pre - existing Condition, until the Covered Plan Participant has been continuously covered
under the Plan for a 12 -month period. This 12 -month Pre - existing Condition exclusionary period begins on the
first day of the Waiting Period for Initial Enrollees; or the Covered Plan Participant's Effective Date of Coverage
under the Plan for Special and Annual Enrollees.
Pre - Existing Conditions Exclusion Period 4-1
Covered Plan Participants with Creditable Coverage at the Initial Enrollment Period
A Covered Plan Participant who enrolls during the Initial Enrollment Period and has Creditable Coverage will be
given credit, beginning the first day of the Waiting Period, for the creditable portion of the Pre - Existing Condition
exclusionary period if that Covered Plan Participant has not satisfied a 12 -month Pre - Existing Condition
exclusionary period. The Covered Plan Participant must furnish certification or relevant corroborating evidence of
Creditable Coverage.
Covered Plan Participants without Creditable Coverage at the Initial Enrollment Period
If a Covered Plan Participant enrolls during the Initial Enrollment Period and does not have Creditable Coverage, a
Pre - existing Condition will not be covered until the Covered Plan Participant has been covered under the Plan for
12 consecutive months from the Effective Date of Coverage.
Covered Plan Participants with Creditable Coverage at the Annual Open Enrollment or Special Enrollment
Periods
A Covered Plan Participant who enrolls during the Annual Open Enrollment Period or Special Enrollment Period
and has Creditable Coverage will be given credit, beginning on the Effective Date of Coverage, for the creditable
portion of the Pre - existing Condition exclusionary period if that Covered Plan Participant has not satisfied a 12-
month Pre - existing Condition exclusionary period. The Covered Plan Participant must furnish certification or
relevant corroborating evidence of Creditable Coverage.
Covered Plan Participants without Creditable Coverage at the Annual Open Enrollment or Special
Enrollment Periods
If a Covered Plan Participant enrolls during the Annual Open Enrollment Period or Special Enrollment Period and
does not have Creditable Coverage, a Pre - existing Condition will not be covered until the Covered Plan Participant
has been covered under the Plan for 12 consecutive months from the Effective Date of Coverage.
Pre - Existing Conditions Exclusion Period 4-2
SECTION 5 - BENEFIT UTILIZATION MANAGEMENT
/UTILIZATION REVIEW PROGRAMS
Introduction
The Keys Physician - Hospital Alliance (KPHA) has agreed to provide certain Utilization Management and
Utilization Review Programs for the Plan. In this regard, KPHA has established various Benefit Utilization
Management/ Utilization Review Programs ( "UM /UR Programs "), including Admission Certification, Outpatient
Diagnostic Procedures & Services Certification, Concurrent Review, Discharge Planning and Catastrophic Claims
Case Management. These programs help facilitate the management and review of coverage and benefits provided
under the Monroe County Group Health Plan Document and, under certain limited circumstances, present
opportunities for alternative benefits or payment alternatives for cost - effective Health Care Services. The UM /UR
Programs and requirements described in this Section will apply as of the date this restatement of the Monroe
Coun Group H. alth Plan Document is approved by the Board of County Commissioners.
Important Information Relating to Keys Physician - Hospital Alliance's UM /UR Programs
All decisions that require or pertain to independent professional medical/ clinical judgement or training, or the need
for medical services, are solely the responsibility of the Covered Plan Participant together with the Covered Plan
Participant's treating Physicians and health care Providers. Covered Plan Participants and their Physicians are
responsible for deciding what medical care should be rendered or received and when and how that care should be
provided. The KPHA is solely responsible for determining whether expenses incurred, or to be incurred, for
medical care are, or would be, covered under the Monroe County Group Health Plan Document. In fulfilling this
responsibility, neither KPHA nor the Plan shall be deemed to participate in or override the medical decisions of any
Covered Plan Participant's health care Provider.
Admission Certification Program
The Admission Certification Program helps KPHA determine, for coverage and payment purposes only, whether
an admission is Medically Necessary as defined herein. In administering the Admission Certification Program,
KPHA may review specific medical facts or information and assess, among other things, the appropriateness, health
care setting and /or the level of care of a Hospital admission. Any reviews or assessments of specific medical facts
or information by KPHA are solely for the purpose of making coverage or payment decisions under the Plan and
not for the purpose of recommending or providing medical care.
Admission Certification Requirements for Inpatient Admissions To Hospitals
The Admission Certification Program requires Covered Plan Participants to obtain from KPHA certification for
ANY admission (e.g., elective, planned, urgent or emergency) to a Hospital. If the Covered Plan Participant fails to
obtain certification from KPHA for the admission, the Allowance for such admission will be reduced b3: 30
as a penalty. This penalty is the Covered Plan Participant's responsibility and is in addition to all applicable
obligations and limitations under the Monroe Coun , Group Health Plan Document (e.g., the Deductible and
Coinsurance requirements) . This penalty amount will not be applied towards the Coinsurance requirement limits
(e.V , the Individual Coinsurance requirement limit.
Benefit Utilization Management /Utilization Review Programs 5-1
Obtaining Pre - admission Certification from Ke,T�ysician- Hospital Alliance (KPHA
Planned Admissions — For all planned admissions (i.e., and inpatient Hospital admission which is not an
emergency or urgent) to a Hospital the Covered Plan Participant must contact KPHA at 305 - 294 -4599 or
800 - 400 -0984 at least three to five days prior to the planned admission for Preadmission Certification &
Length of Stay Approval. This means that KPHA must certify the hospital admission and approve the
number of days for which certification is given, before the services are provided. If the Hospital
admission is denied, but the Covered Plan Participant is admitted to the Hospital anyway, benefits
for Covered Services will be reduced by 30% of covered charges. If confinement extends beyond the
approved Length of Stay, additional days must be pre - certified by KPHA. Full benefits for hospital charges
will be paid only for the approved number of extended confinement days. All covered charges incurred
during that hospitalization will be reduced by 30 percent for those extended confinement days not
approved.
2. Unplanned Admissions — For all unplanned admissions (i.e., an inpatient Hospital admission that is an
emergency or is urgent or cannot be scheduled in advance) to a Hospital the Covered Plan Participant must
ensure that the Physician or the Hospital contacts KPHA by telephone within 24 hours of the admission or
the first business day following a weekend or holiday admission. In the event the Covered Plan Participant's
Condition makes it impossible for the Covered Plan Participant to ensure that KPHA is so notified within
the applicable time frame, the Covered Plan Participant must ensure that KPHA is so notified as soon as
possible.
3. KPHA's Certification Decision — Once KPHA has received and reviewed the necessary information,
KPHA will make a certification decision, for coverage and payment purposes only, based upon the
Admission Certification program's criteria then in effect. KPHA will notify the Covered Plan Participant,
the Physician and the Hospital of the certification decision as soon as possible.
Outpatient Diagnostic Procedures & Services Certification
For scheduled, non - emergency Outpatient Diagnostic Procedures (e.g., MRI, CT Scan) and Services (e.g., Durable
Medical Equipment, Home Health Services) the Covered Plan Participant must contact KPHA at 305 - 294 -4599 or
800 - 400 -0984 at least three to five days prior to the scheduled procedure. KPHA will review for determination of
medical necessity.
Below is a list of outpatient diagnostic procedures and services that require Certification from KPHA prior to the
scheduled Diagnostic Procedure and /or Services.
• Certification must be obtained on ALL MRI, MRA, CTA, CT Scans and PET Scans;
• Certification must be obtained on ALL Outpatient physical, occupational & speech therapy referrals;
• Certification must be obtained on ALL 30 -day Outpatient Cardiac Therapy;
• Certification must be obtained on ALL sleep studies and follow -up titration studies in conjunction with
CPAP referrals;
• Certification must be obtained on ALL TMJ care and prescribed Orthotic Devices;
• Certification must be obtained on ALL Durable Medical Equipment (i.e., wheelchairs, hospital beds, CPAP
machines, oxygen); and
• Certification must be obtained on ALL Home Health Service
Benefit Utilization Management /Utilization Review Programs 5-2
In the event the Covered Plan Participant fails to obtain prior certification from KPHA on any Procedure and /or
Service listed above the Allowed Amount will be reduced b,T� percent as a penalty. This penalty is the Covered
Plan Participant's responsibility and is in addition to all applicable obligations and limitations under the Monroe
Coun , Group Health Plan Document (e.g., the Deductible and Coinsurance requirements) . This penalty amount
will not be applied towards the Coinsurance requirement limits (e.g., the Individual Coinsurance requirement limit.
Concurrent Review Program
Under this UM /UR program, KPHA will review Hospital stays and other health care treatment programs during
the course of such stay or treatment program. Any such review is conducted solely to determine whether coverage
and /or payment should continue for a particular admission. Using established criteria then in effect, concurrent
review of the Hospital stay will occur at regular intervals. KPHA will provide the Covered Plan Participant's
Physician with notification when KPHA's criteria under this program for coverage and payment for continued
inpatient care are no longer met. In administering the Concurrent Review Program, KPHA may review specific
medical facts or information and assess, among other things, the appropriateness, health care setting and /or the
level of care of a Hospital admission. Any reviews or assessments of specific medical facts or information by
KPHA are solely for the purpose of making coverage or payment decisions under the Plan and not for the purpose
of recommending or providing medical care.
Discharge Planning
Under this UM /UR program KPHA will help the Covered Plan Participant and the Covered Plan Participant's
Physician identify health care resources that may be available in the Covered Plan Participant's community
following hospitalization. KPHA will, upon request, answer questions the Covered Plan Participant's Physician has
regarding the Covered Plan Participant's coverage or benefits under the Monroe County Group Health Plan
Document following discharge from the Hospital.
Case Management Program
Under this UM /UR program KPHA provides Case Management services for those Covered Plan Participants who
have a catastrophic or chronic condition. KPHA case managers act as liaison between the Covered Plan
Participant, Physician, Therapist, Third Party Administrator and Employer coordinating all services so that each
Covered Plan Participant can return to their optimal potential. Examples of catastrophic illnesses or injuries
include, but are not limited to:
• Major Head Trauma and Brain Injury Secondary to Illness
• Amyotrophic Lateral Sclerosis (ALS)
• Multiple Sclerosis (MS)
• Neonatal High Risk Infant
• Spinal Cord Injuries
• Multiple Fractures
• Severe Burns
• Amputations
• Transplants
• Leukemia
• Cancer
• AIDS
• Home Health Needs
• Durable Medical Equipment Needs
• Any Claim expected to exceed $30,000
Benefit Utilization Management /Utilization Review Programs 5-3
When KPHA is notified of one of the above diagnoses or needs (or any other diagnosis for which KPHA feels
Case Management is appropriate) by the Covered Plan Participant, Physician, or Wells Fargo TPA, the KPHA Case
Manager will develop a plan of treatment which will include all services and supplies to be utilized, as well as the
most appropriate treatment setting. The treatment plan may be modified as the Covered Plan Participant's
condition or needs change.
Under this program the Plan and KPHA may elect to (but is not required to) offer alternative benefits or payment
for cost - effective Health Care Services. These alternative benefits or payments may be made available on a case -by-
case basis to Covered Plan Participants who meet KPHA criteria then in effect. Such alternative benefits or
payments, if any, will be made available in accordance with a treatment plan with which the Covered Plan
Participant and the Covered Plan Participant's Physician agree.
Offering to provide, or actually, providing any alternative benefits or payments in no way obligates the Plan or
KPHA to continue to provide such alternative benefit payments, or to provide alternative benefits or payments to
the Covered Plan Participant or any other person insured by the Plan at any time. Nothing contained in this section
shall be deemed a waiver of the Plan's right to enforce the Monroe County Group Health Plan Document in strict
accordance with its terms.
Appeal Process
The Covered Plan Participant, a treating Physician or a Hospital may request that KPHA review a UM /UR
Program coverage or payment decision, provided such request is received by KPHA in writing within 90 days of the
date of the decision. The review request must include all information deemed relevant or necessary by KPHA.
KPHA will review the decision in light of such information and notify the Monroe County Group Health Plan
Administrator of the review decision. Upon approval from the Monroe County Group Health Plan Administrator
the KPHA will notify the Covered Plan Participant, the Hospital and /or the Physician of the final decision.
Benefit Utilization Management /Utilization Review Programs 5-4
SECTION 6 - MEDICAL NECESSITY
In order for Health Care Services to be covered under the Monroe County Group Health Plan, such services must
be: 1) not otherwise limited or excluded under the Monroe County Group Health Plan Document; 2) rendered
while coverage is in force; 3) within the service categories set forth in the Covered Services section; and 4) Medically
Necessary, as defined in the Definitions section of the Monroe County Group Health Plan Document.
It is important to remember that any review of Medical Necessity by Wells Fargo TPA, KPHA or the Monroe
County Group Health Plan Administrator is solely for the purposes of determining coverage or benefits under the
Monroe County Group Health Plan Document and not for the purpose of recommending or providing medical
care. In this respect, Wells Fargo TPA, KPHA or Monroe County Group Health Plan Administrator may review
specific medical facts or information pertaining to a Covered Plan Participant. Any such review, however, is strictly
for the purpose of determining, among other things, whether a Health Care Service provided or proposed meets the
applicable coverage and payment guidelines then in effect.
All decisions that require or pertain to independent professional medical/ clinical judgement or training, or the need
for medical services, are the sole responsibility of the Covered Plan Participant and the Covered Plan Participant's
treating Physicians and health care Providers. Covered Plan Participants and their Physicians are responsible for
deciding what medical care should be rendered or received and when that care should be provided. In making
coverage decisions, neither Wells Fargo TPA nor KPHA nor the Monroe County Group Health Plan Administrator
shall be deemed to participate in or override the medical decisions of a Covered Plan Participant or a Covered Plan
Participant's health care Providers.
Examples of hospitalization and other Health Care Services that are not Medically Necessary include, but are not
limited to:
1. continued hospitalization because arrangements for discharge have not been completed;
2. use of laboratory, x -ray, or other diagnostic testing that has no clear indication, or is not expected to alter
the treatment plan;
3. hospitalization because supervision in the home, or care in the home, is inconvenient; or hospitalization for
any service which could have been provided adequately in an alternate setting (e.g., Hospital outpatient
department); or
4. inpatient admissions to a Hospital, Skilled Nursing Facility, or any other facility for the purpose of Custodial
Care, convalescent care, or any other service primarily for the convenience of the patient and /or his /her
family members.
Medical Decisions - Responsibility of Covered Plan Participant
Any and all decisions that require or pertain to independent professional medical judgement or training, or the need
for medical services or supplies, must be made solely by the Covered Plan Participant, the Covered Plan
Participant's family and the Covered Plan Participant's treating Physician in accordance with the patient /physician
relationship. It is possible that the Covered Plan Participant or the Covered Plan Participant's treating Physician
may conclude that a particular procedure is needed, appropriate, or desirable, even though such procedure may not
be covered.
Note: Whether or not a Health Care Service is specifically listed as an exclusion, the fact that a Provider
may prescribe, recommend, approve, or furnish a Health Care Service does not mean that the service is
Medically Necessary (as defined by the Monroe County Group Health Plan Document) or a Covered
Service. Please refer to the Definitions section of the Monroe County Group Health Plan Document for
the definitions of "Medically Necessary" or "Medical Necessity."
Medical Necessity 6-1
SECTION 7 - COVERED SERVICES
Introduction
The following subsections describe the Health Care Services which may be Covered Services under the Monroe
County Group Health Plan Document. All benefits for Covered Services are subject to the Covered Plan
Participant's applicable financial responsibilities, benefit maximums (e.g., Calendar Year Deductible and Lifetime
Maximum), the applicable Allowed Amount, limitations, exclusions, and all other provisions contained in the
Monroe County Group Health Plan Document (including the Schedule of Benefits) in accordance with Wells Fargo
TPA's Medical Necessity criteria and guidelines then in effect.
Expenses for the Health Care Services listed below will be covered under the Plan only if the services are:
1. within the services' categories set forth in this Covered Services section;
2. rendered by appropriate licensed health care Provider who is recognized for payment herein;
3. Medically Necessary as defined in the Monroe County Group Health Plan Document;
4. rendered while a Covered Plan Participant's coverage is in force; and
5. not specifically or generally limited (e.g., Pre - existing Condition exclusionary period) or excluded under the
Monroe County Group Health Plan Document.
Note: More than one limitation or exclusion may apply to a specific Health Care Service or a particular situation.
Under most circumstances, Wells Fargo TPA will determine whether Health Care Services are Covered Services
under the Plan when processing a Covered Plan Participant's claim after the Covered Plan Participant has obtained
such services and a claim has been received by Wells Fargo TPA for such services. In some circumstances, Wells
Fargo TPA or the Monroe County Group Health Plan Administrator may, but are not required to, determine
whether Health Care Services are Covered Services under the Monroe County Group Health Plan Document
before the Covered Plan Participant is provided the service. For example, Wells Fargo TPA or the Monroe County
Group Health Plan Administrator may determine whether a proposed transplant is a Covered Service under the
Monroe County Group Health Plan Document before such transplant is provided.
Benefit Guidelines
In providing benefits for Covered Services, the benefit guidelines set forth below apply as well as any other
applicable reimbursement rules specific to particular categories of Heath Care Services:
1. The reimbursement for certain Health Care Services is included within the Allowed Amount for the primary
procedure, and therefore no additional amount is payable for any such services and /or supplies.
2. The reimbursement is based on the Allowed Amount for the actual service rendered (i.e., not based on the
Allowed Amount for a service which is more complex than the service actually rendered), and is not based
on the method utilized to perform the service nor the day of the week nor the time of day the procedure is
performed.
3. The reimbursement for a service includes all components of the service when such service can be described
by a single procedure code, or when the service is an essential or integral part of the associated
therapeutic /diagnostic service.
Covered Services 7-1
Covered Services Categories
The Health Care Services listed below may be Covered Services under the Monroe County Group Health Plan
Document. For ease of reference, limitations and exclusions which apply to specific services have been included in
this section. Any specific limitations and /or exclusions included in this section are in addition to any other
limitations and /or exclusions listed in the Monroe County Group Health Plan Document including those listed in
the General Exclusions section.
• Accident Care
Health Care Services to treat an injury or illness resulting from an Accident not arising as a result of the Covered
Plan Participant's job or employment.
• Adult Wellness Services
Refer to the Schedule of Benefits for Covered Services and benefit maximums.
Exclusion Any charges over the maximum allowable of $400 by the Plan are the responsibility of the Covered
Plan Participant and do not count toward the Individual Coinsurance Responsibility Limit Per Calendar Year.
• Allergy Testing and Treatments
Testing and desensitization therapy (e.g., injections) and the cost of hyposensitization serum. The Allowed Amount
for allergy testing is based upon the type and number of tests performed by the Physician. The Allowed Amount
for allergy immunotherapy treatment is based upon the type and number of doses.
• Ambulance Services
Ambulance services (ground or air) to transport a Covered Plan Participant from:
1. a Hospital unable to provide proper care to the nearest Hospital that can provide proper care;
2. a Hospital to the Covered Plan Participant's nearest home or Skilled Nursing Facility; or
3. the place a medical emergency occurs to the nearest Hospital that can provide proper care.
• Ambulatory Surgical Centers
Health Care Services rendered at an Ambulatory Surgical Center including:
1. use of operating and recovery rooms;
2. respiratory, or inhalation therapy (e.g., oxygen);
3. drugs and medicines administered (except for take home drugs) at the Ambulatory Surgical Center;
4. intravenous solutions;
5. dressings, including ordinary casts;
6. anesthetics and their administration;
7. administration of, including the cost of, whole blood or blood products;
8. transfusion supplies and equipment;
9. diagnostic services, including radiology, ultrasound, laboratory, pathology and approved machine testing
(e.g., EKG); and
10. chemotherapy treatment for proven malignant disease.
Covered Services 7-2
• Anesthesia Administration Services
Administration of anesthesia by a Physician or Certified Registered Nurse Anesthetist ( "CRNA "). In those
instances where the CRNA is actively directed by a Physician other than the Physician who performed the surgical
procedure, payment for Covered Services, if any, will be made for both the CRNA and the Physician services at the
lower directed - services Allowed Amount in accordance with the payment program for such services then in effect.
Exclusion — Coverage does not include anesthesia services by an operating Physician, his or her partner or
associate.
• Autism
The following services are covered as they relate to "Autism Spectrum Disorder" defined as autism disorder,
Asperger's Syndrome, and other pervasive developmental disorders not otherwise specified. Well -baby and well -
child screening for diagnosing the presence of autism spectrum disorder, and Treatment of autism spectrum
disorder through: Therapy, including Speech, Occupational and /or Physical Therapy; and Applied Behavior
Analysis, which is the design, implementation and evaluation of environmental modifications, using behavioral
stimuli and consequences, to produce socially significant improvement in human behavior.
To be eligible for services, the Covered Plan Participant must be under 18 years of age; or 18 years of age or older
in high school and diagnosed as having a developmental disability at 8 years of age or younger.
Exclusion — The Plan will not pay for Covered Services which exceed the annual or lifetime maximums for Autism
Spectrum Disorder listed in the Schedule of Benefits.
• Breast Reconstructive Surgery
Breast Reconstructive Surgery and implanted prostheses incident to Mastectomy. In order to be covered, such
surgery must be provided in a manner chosen by the Covered Plan Participant's Physician, consistent with
prevailing medical standards, and in consultation with the Covered Plan Participant.
• Child Cleft Lip and Cleft Palate Treatment
Treatment and services for Child Cleft Lip and Cleft Palate, including medical, dental, Speech Therapy, audiology,
and nutrition services for treatment of a child under the age of 18 who has cleft lip or cleft palate. In order for such
services to be covered, the Covered Plan Participant's Physician must specifically prescribe such services and such
services must be consequent to treatment of the cleft lip or cleft palate.
• Concurrent Physician Care
Physician medical services, provided: (a) the additional Physician actively participates in the Covered Plan
Participant's treatment; (b) the Condition involves more than one body system or is so severe or complex that one
Physician cannot provide the care unassisted; and (c) the Physicians have different specialties or have the specialty
with different sub - specialties.
Covered Services 7-3
• Consultations
Consultations provided by a Physician are covered if the attending Physician requests the consultation and the
consulting Physician prepares a written report.
• Dental
Dental Care is limited to the following:
Care and treatment initiated within 90 days of an Accidental Dental Injury provided such services are for the
treatment of damage to sound natural teeth.
2. Extraction of teeth required prior to radiation therapy when the Covered Plan Participant has a diagnosis of
cancer of the head and /or neck.
3. Anesthesia services for dental care including general anesthesia and hospitalization services necessary to
assure the safe delivery of necessary dental care provided to a Covered Plan Participant in a Hospital or
Ambulatory Surgical Center if-
a. the Covered Plan Participant is under 8 years of age and it is determined by a dentist and the
Covered Plan Participant's Physician that: 1) dental treatment is necessary due to a dental Condition
that is significantly complex; or 2) the Covered Plan Participant has a developmental disability in
which patient management in the dental office has proven to be ineffective; or
b. the Covered Plan Participant has one or more medical Conditions that would create significant or
undue medical risk for the Covered Plan Participant in the course of delivery of any necessary dental
treatment or surgery if not rendered in a Hospital or Ambulatory Surgical Center.
4. Oral Surgery limited to the following procedures:
a. Health Care Services provided for the excision of impacted teeth at any location (i.e., inpatient
hospital, surgery, associated x -rays and anesthesia); and
b. Apicoectomy (excision of tooth root without extraction of the tooth); and
c. Cutting procedures on the gums and mouth tissues for treatment of disease; and /or
Cl. Osseous surgery to modify and reshape deformities in the supporting bone around the teeth and is
used when periodontal disease is advanced in nature.
Exclusion — Dental Services provided more than 90 days after the date of an Accidental Dental Injury regardless of
whether or not such services could have been rendered within 90 days; and Dental Implants.
• Diabetes Outpatient Self- Management
Diabetes outpatient self - management training and educational services and nutrition counseling (including all
medically appropriate and necessary equipment and supplies) to treat diabetes, if the Covered Plan Participant's
treating Physician or a Physician who specializes in the treatment of diabetes certifies that such services are
necessary. In order to be covered, diabetes outpatient self - management training and educational services must be
provided under the direct supervision of a certified Diabetes Educator or a board - certified Physician specializing in
endocrinology. Additionally, in order to be covered, nutrition counseling must be provided by a licensed Dietitian.
Covered Services 7-4
Covered Services may also include the trimming of toenails, corns, calluses, and therapeutic shoes (including inserts
and /or modifications) for the treatment of severe diabetic foot disease.
• Diagnostic Services
Diagnostic services when ordered by a Physician are limited to the following:
• radiology, ultrasound and nuclear medicine, Magnetic Resonance Imaging (MRI);
• laboratory and pathology services;
• services involving bones or joints of the jaw (e.g., services to treat temporomandibular joint (TMJ)
dysfunction) or facial region if, under accepted medical standards, such diagnostic services are necessary to
treat Conditions caused by congenital or developmental deformity, disease, or injury;
• approved machine testing (e.g., electrocardiogram (EKG), and other electronic diagnostic medical
procedures); and
• genetic testing for the purposes of explaining current signs and symptoms of a possible hereditary disease.
• Dialysis Services
Including equipment, training, and medical supplies, when provided at any location, by a Dialysis Center or a
Provider licensed to perform dialysis.
• Durable Medical Equipment
Durable Medical Equipment (DME) when provided by a Durable Medical Equipment Provider and when
prescribed for a Covered Plan Participant by a Physician, limited to the most cost effective Durable Medical
Equipment, which meets the Covered Plan Participant's needs as determined by KPHA.
Reimbursement Guidelines for Durable Medical Equipment (DME)
Supplies and service to repair medical equipment may be Covered Services only if the Covered Plan Participant
owns the equipment or is purchasing the equipment. The Allowed Amount for DME will be the lowest of the
following: 1) the purchase price; 2) the lease /purchase price; 3) the rental rate; or 4) the Allowed Amount. The
total Allowed Amount for such rental equipment will not exceed the total purchase price. DME includes, but is not
limited to, the following: wheelchairs, crutches, canes, walkers, hospital beds, and oxygen equipment.
Note: Repair or replacement of Durable Medical Equipment due to growth of a child or due to a change in the
Covered Plan Participant's Condition is a Covered Service.
Exclusion — Equipment which is primarily for the convenience and /or comfort of the Covered Plan Participant,
the Covered Plan Participant's family or caretakers; modifications to motor vehicles and /or homes such as
wheelchair lifts or ramps; electric scooters; water therapy devices such as Jacuzzis, hot tubs, swimming pools or
whirlpools; exercise and massage equipment; hearing aids; air conditioners and purifiers; humidifiers; water
softeners and /or purifiers; pillows, mattresses or waterbeds; escalators, elevators, stair glides; emergency alert
equipment; handrails and grab bars; heat appliances and dehumidifiers; and the replacement of Durable Medical
Equipment solely because it is old or used are excluded.
Covered Services 7-5
In the event the Covered Plan Participant fails to obtain prior certification from KPHA on any Durable Medical
Equipment the Allowed Amount will be reduced b,T� 30 percent as a penalty. This penalty is the Covered Plan
Participant's responsibility and is in addition to all applicable obligations and limitations under the Monroe Count
Group Health Plan Document (e.g., the Deductible and Coinsurance requirements). This penalty amount will not
be applied towards the Coinsurance requirement limits (e.V., the Individual Coinsurance requirement limit.
• Enteral Formulas
Prescription and non - prescription enteral formulas for home use when prescribed by a Physician as necessary to
treat inherited diseases of amino acid, organic acid, carbohydrate or fat metabolism as well as malabsorption
originating from congenital defects present at birth or acquired during the neonatal period.
Coverage to treat inherited diseases of amino acid or organic acids, for any Covered Plan Participant up to their 25th
birthday, shall include coverage for food products modified to be low protein.
Benefits for low protein food products are limited as set forth in the Schedule of Benefits.
• Eye Care
Coverage includes the following services:
1. Physician services, soft lenses or sclera shells, for the treatment of aphakic patients;
2. initial glasses or contact lenses following cataract surgery; and
3. Physician services to treat an injury or disease to a Covered Plan Participant's eyes.
Exclusion — Health Care Services to diagnose or treat vision problems which are not a direct consequence of
trauma or prior ophthalmic surgery; eye examinations; eye exercises or visual training; eye glasses and contact lenses
and their fitting are excluded. In addition to the above, any surgical procedure performed primarily to correct or
improve myopia or other refractive disorders (e.g., radial keratotomy, PRK and LASIK) are excluded.
• Home Health Care
The following Home Health Care Services only when: 1) the Home Health Care Services are provided directly by
(or indirectly through) a Home Health Agency; 2) the Home Health Care Services rendered have been prescribed
by a Physician by way of a formal written treatment plan that has been reviewed and renewed by the Covered Plan
Participant's Physician every 30 days; 3) the Covered Plan Participant is meeting or achieving the desired treatment
goals set forth in the treatment plan as documented in the clinical progress notes; and 4) the Covered Plan
Participant is confined to home and is unable to carry out the basic activities of daily living.
Home Health Care Services are limited to:
1. part -time (i.e., less than 8 hours per day and less than a total of 40 hours in a calendar week) or intermittent
(i.e., a visit of up to, but not exceeding, 2 hours per day) nursing care by a Registered Nurse or Licensed
Practical Nurse and /or home health aide Services;
2. home health aide Services must be consistent with the plan of treatment, ordered by a Physician, and
rendered under the supervision of a Registered Nurse,
3. medical social services;
4. nutritional guidance;
5. respiratory, or inhalation therapy (e.g., oxygen); and
Covered Services 7-6
6. Physical Therapy by a Physical Therapist, Occupational Therapy by a Occupational Therapist, and Speech
Therapy by a Speech Therapist.
Benefits for Covered Services for Home Health Care are limited as set forth in the Schedule of Benefits. In the
event the Covered Plan Participant fails to obtain prior certification from KPHA on any Home Health Care the
Allowed Amount will be reduced b,T� 30 percent as a penalty. This penalty is the Covered Plan Participant's
responsibility and is in addition to all applicable obligations and limitations under the Monroe Coun , Group
Health Plan Document (ems. ., the Deductible and Coinsurance requirements) . This penalty amount will not be
applied towards the Coinsurance requirement limits (e.g., the Individual Coinsurance requirement limit.
Exclusion -
1. any Home Health Care service which is not directly provided by (or indirectly provided) through a Home
Health Agency;
2. homemaker services; domestic maid services;
3. sitter services; companion services;
4. services rendered by an employee or operator of an adult congregate living facility; an adult foster home; an
adult day care center; or a nursing home facility;
5. Custodial Care except for any such care covered under this subsection when provided on a part -time or
intermittent basis (as defined above) by a home health aide;
6. food, housing, and home delivered meals.
• Hospice Services
Health Care Services provided to a Covered Plan Participant in connection with a Hospice treatment program may
be Covered Services, provided the Hospice treatment program is approved by the Covered Plan Participant's
Physician and the Covered Plan Participant is not expected to live more than one year. Wells Fargo TPA shall have
the right to request that a Covered Plan Participant's Physician certify in writing the life expectancy of a Covered
Plan Participant.
• Hospital Services
Covered Hospital Services including:
1. room and board in a semi - private room when confined as an inpatient, unless the patient must be isolated
from others for documented clinical reasons;
2. intensive care units, including cardiac, progressive and neonatal care;
3. use of operating and recovery room;
4. use of emergency rooms;
5. respiratory, pulmonary, or inhalation therapy (e.g., oxygen);
6. drugs and medicines administered (except for take home drugs) by the Hospital;
7. intravenous solutions;
8. administration of, including the cost of, whole blood or blood products;
9. dressings, including ordinary casts;
10. anesthetics and their administration;
11. transfusion supplies and equipment;
12. diagnostic services, including radiology, ultrasound, laboratory, pathology, and approved machine testing
(e.g., EKG);
13. Physical, Speech, Occupational, Cardiac Therapies; and
14. transplants as set forth in the Transplant subsection.
Covered Services 7-7
Exclusion — Expense for the following Hospital Health Care Services are excluded when such services could have
been provided without admitting the Covered Plan Participant to the Hospital: 1) room and board provided during
the Covered Plan Participant's admission; 2) Physician visits provided while the Covered Plan Participant was an
inpatient; and 3) Occupational Therapy, Speech Therapy, Physical Therapy, Cardiac Therapy; and 4) other Services
provided while the Covered Plan Participant was inpatient.
In addition, expenses for the following are also excluded:
1. gowns and slippers;
2. shampoo, toothpaste, body lotions and hygiene packets;
3. take -home drugs;
4. telephone and television;
5. guest meals or gourmet menus; and
6. admission kits.
• Inpatient Rehabilitation
Inpatient Rehabilitation Services are covered when the following criteria are met:
1. Services must be provided under the direction of a Physician and must be provided by a Medicare certified
facility in accordance with a comprehensive rehabilitation program;
2. a plan of care must be developed and managed by a coordinated multi - disciplinary team;
3. coverage is limited to the specific acute, catastrophic target diagnoses of severe stroke, multiple trauma,
brain /spinal injury, severe neurological motor disorders, and /or severe burns;
4. the Covered Plan Participant must be able to actively participate in at least 2 rehabilitative therapies and be
able to tolerate at least 3 hours per day of skilled Rehabilitation Services for at least 5 days a week and their
Condition must be likely to result in significant improvement; and
5. the Rehabilitation Services must be required at such intensity, frequency and duration as to make it
impractical for the individual to receive services in a less intensive setting.
Exclusion: Pain Management and respiratory ventilator management Services are excluded.
• Massage Therapy
Massage provided by a Physician, Massage Therapist, or Physical Therapist when the massage therapy is prescribed
as being Medically Necessary by a Physician licensed pursuant to Florida Statutes Chapter 458 (Medical Practice),
Chapter 459 (Osteopathy), Chapter 460 (Chiropractic) or Chapter 461 (Podiatry) is covered. The Covered Plan
Participant's Physician's prescription must specify the number of treatments.
Exclusion — Application or use of the following or similar technique or items for the purpose of aiding in the
provisions of a Massage: hot or cold packs; hydrotherapy; colonic irrigation; thermal therapy; chemical or herbal
preparations; paraffin baths; infrared light; ultraviolet light, Hubbard tank, contrast baths are excluded.
Benefits for Covered Services for Massage Therapy are limited as set forth in the Schedule of Benefits.
Covered Services 7-8
• Mammograms
Mammograms obtained in a medical office, medical treatment facility or through a health testing service that uses
radiological equipment registered with the appropriate Florida regulatory agencies (or those of another state) for
diagnostic purposes or breast cancer screening, are Covered Services.
Routine mammograms are limited to the following per Florida Statute:
• A baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age;
• A mammogram every 2 years for any woman who is 40 years of age or older, but younger than 50 years of
age, or more frequently based on the Covered Plan Participant's Physician's recommendation;
• A mammogram every year for any woman who is 50 years of age or older;
• One or more mammograms a year, based upon a Physician's recommendation, for any woman who is at
risk for breast cancer because of a personal or family history of breast cancer, because of having a history of
biopsy - proven benign breast disease, because of having a mother, sister, or daughter who has or has had
breast cancer, or because a woman has not given birth before the age of 30.
The Plan covers 100% of the cost of routine mammograms as outlined above. Per Section 627.6613, Florida
Statutes, there is no additional charge to the Covered Plan Participant for routine mammograms when rendered b
a PPO Network Provider, including but not limited to the Calendar Year Deductible and Coinsurance.
• Mastectomy Services
Breast cancer treatment including treatment for physical complications relating to a Mastectomy (including
lymphedemas), and outpatient post - surgical follow -up in accordance with prevailing medical standards as
determined by the Covered Plan Participant's attending Physician and the Covered Plan Participant. Outpatient
post - surgical follow -up care for Mastectomy services shall be covered when provided by a Provider in accordance
with the prevailing medical standards and at the most medically appropriate setting. The setting may be the
Hospital, Physician's office, outpatient center, or home of the Covered Plan Participant. The treating Physician,
after consultation with the Covered Plan Participant, may choose the appropriate setting.
• Maternity Services
Health Care Services, including prenatal care, delivery and postpartum care and assessment, provided to a Covered
Plan Participant, by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Hospital, Birth Center, Midwife or
Certified Nurse Midwife may be Covered Services. Care for the mother includes the postpartum assessment.
In order for the postpartum assessment to be covered, such assessment must be provided at a Hospital, an
attending Physician's office, an outpatient maternity center, or in the home by a qualified licensed health care
professional trained in care for a mother. Coverage under the Plan for the postpartum assessment includes
coverage for the physical assessment of the mother and any necessary clinical tests in keeping with prevailing
medical standards.
• Mental Health Services
Diagnostic evaluation, psychiatric treatment, individual therapy, and group therapy provided to a Covered Plan
Participant by a Physician, Psychologist, or Mental Health Professional for the treatment of a Mental Health
Professional for the treatment of a Mental and Nervous Disorder may be covered. These Health Care Services
include inpatient, outpatient, and Partial Hospitalization services.
Covered Services 7-9
Partial Hospitalization is a Covered Service when provided under the direction of a Physician and in lieu of
inpatient hospitalization and is combined with the inpatient Hospital benefit.
Exclusion
1. Services rendered in connection with a Condition not classified in the diagnostic categories of the
International Classification of Diseases, Ninth Edition, Clinical Modification (ICD -9 CM) or their
equivalents in the most recently published version of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders regardless of the underlying cause, or effect, of the disorder;
2. Services for psychological testing associated with the evaluation and diagnosis of learning disabilities or for
mental retardation;
3. Services extended beyond the period necessary for evaluation and diagnosis of learning disabilities or for
mental retardation;
4. Services for marriage counseling, when not rendered in connection with a Condition not classified in the
diagnostic categories of the International Classification of Diseases, Ninth Edition, Clinical Modification
(ICD -9 CM) or their equivalents in the most recently published version of the American Psychiatric
Association's Diagnostic and Statistical Manual of Mental Disorders;
5. Services for pre - marital counseling;
6. Services for court ordered care or testing, or required as a condition of parole or probation;
7. Services for testing aptitude, ability, intelligence or interest;
8. Services for testing and evaluation for the purpose of maintaining employment;
9. Services for cognitive remediation;
10. inpatient confinements that are primarily intended as a change of environment; or
11. inpatient (over night) mental health services received in a residential treatment facility.
• Newborn Care
A newborn child of a Covered Plan Participant shall be covered from the moment of birth provided that the
newborn child is eligible for coverage and properly enrolled. Covered Services shall consist of coverage for injury
or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities,
and premature birth.
Newborn Assessment
An assessment of the newborn child provided the services were rendered at a Hospital, at the attending Physician's
office, at a Birth Center, or in the home by a Physician, Midwife or Certified Nurse Midwife, and the performance
of any necessary clinical tests and immunizations in keeping with prevailing medical standards.
Expenses for these services are not subject to the Calendar Year Deductible, but are subject to the Coinsurance.
Ambulance services, when necessary to transport the newborn child to and from the nearest appropriate facility
which is staffed and equipped to treat the newborn child's Condition, as determined by Wells Fargo TPA and
certified by the attending Physician as Medically Necessary to protect the health and safety of the newborn child.
• Orthotic Devices
Orthotic Devices including braces and trusses for the leg, arm, neck and back, and special surgical corsets when
prescribed by a Physician.
Covered Services 7-10
Benefits may be provided for necessary replacement of an Orthotic Device which is owned by the Covered Plan
Participant when due to irreparable damage, wear, a change in Covered Plan Participant's Condition, or when
necessitated due to growth of a child.
Reimbursements for splints for the treatment of temporomandibular joint ( "TMJ ") dysfunction is limited to
payment for one splint in a six -month period unless determined by KPHA to be Medically Necessary.
Exclusion
1. Expenses for arch supports, shoe inserts designed to effect conformational changes in the foot or foot
alignment, orthopedic shoes, over - the - counter, custom -made or built -up shoes, cast shoes, sneakers, ready -
made compression hose or support hose, or similar type devices /appliances regardless of intended use,
except for therapeutic shoes (including insert and /or modifications) for the treatment of severe diabetic foot
disease;
2. Expenses for orthotic appliances or devices which straighten or re -shape the conformation of the head or
bones of the skull or cranium through cranial banding or molding (e.g. dynamic orthotic cranioplasty or
molding helmets), except when the orthotic appliance or device is used as an alternative to an internal
fixation device as a result of surgery for craniosynostosis; and
3. Expenses for devices necessary to exercise, train, or participate in sports, (e.g., custom -made knee braces).
Benefits for Covered Services for TM Services are limited as set forth in the Schedule of Benefits. In the event the
Covered Plan Participant fails to obtain prior certification from KPHA on any Orthotic Device the Allowed
Amount will be reduced b,T� percent as a penalty. This penalty is the Covered Plan Participant's responsibility
and is in addition to all applicable obligations and limitations under the Monroe Coun , Group Health Plan
Document (e.g., the Deductible and Coinsurance requirements) . This penalty amount will not be applied towards
the Coinsurance requirement limits (ems., the Individual Coinsurance requirement limit.
• Osteoporosis Screening, Diagnosis, and Treatment
Screening, diagnosis, and treatment of osteoporosis for high -risk individuals is covered, including, but not limited
to:
1. estrogen- deficient individuals who are at clinical risk for osteoporosis;
2. individuals who have vertebral abnormalities;
3. individuals who are receiving long -term glucocorticoid (steroid) therapy; or
4. individuals who have primary hyperparathyroidism, and individuals who have a family history of
osteoporosis.
• Outpatient Cardiac, Occupational, Physical, Speech, and Spinal Manipulation
1. Outpatient therapies listed below when ordered by a Physician or other health care professional licensed to
perform such services:
• Cardiac Therapy: Services provided under the supervision of a Physician, or an appropriate Provider
trained for Cardiac Therapy, for the purpose of aiding in the restoration of normal heart function in
connection with a myocardial infarction, coronary occulusion or coronary bypass surgery.
• Occupational Therapy: Services provided by a Physician or Occupational Therapist for the purpose
of aiding in the restoration of a previously impaired function lost due to a Condition.
• Physical Therapy: Services provided by a Physician or Physical Therapist for the purpose of aiding in
the restoration of normal physical function lost due to a Condition.
Covered Services 7-11
• Speech Therapy: Services of a Physician, Speech Therapist, or licensed audiologist to aid in the
restoration of speech loss or an impairment of speech resulting from a Condition.
Benefits for Covered Services for Outpatient Cardiac, Occupational, Ph sT�, Speech Therapies are limited as set
forth in the Schedule of Benefits. In the event the Covered Plan Participant fails to obtain prior certification from
KPHA on any Cardiac, Occupational, Physical or Speech Therapies the Allowed Amount will be reduced by 30
percent as a penalty. This penalty is the Covered Plan Participant's responsibility and is in addition to all applicable
obligations and limitations under the Monroe Coun , Group Health Plan Document (e.V , the Deductible and
Coinsurance requirements) . This penalty amount will not be applied towards the Coinsurance requirement limits
(e.V , the Individual Coinsurance requirement limit.
Exclusion — Application or use of the following or similar techniques or items for the purpose of aiding in the
provision of a Massage: hot or cold packs; hydrotherapy; colonic irrigation; thermal therapy; chemical or herbal
preparations; paraffin baths; infrared light; ultraviolet light; Hubbard tank, contrast baths are excluded.
• Spinal Manipulations: Services by Physicians for manipulations of the spine to correct a slight dislocation
of a bone or joint that is demonstrated by x -ray.
Benefits for Covered Services for Spinal Manipulations are limited as set forth in the Schedule of Benefits.
• Oxygen
Expenses for oxygen, the equipment necessary to administer it, and the administration of oxygen are covered.
• Physician Services
Medical or surgical Health Care Services provided by a Physician, including Services rendered in the Physician's
office, in an outpatient facility.
• Preventive Child Health Supervision Services
Periodic Physician - delivered or Physician - supervised services from the moment of birth up to the 17th birthday as
follows:
1. periodic examinations, which include a history, a physical examination, and a developmental assessment and
anticipatory guidance necessary to monitor the normal growth and development of a child;
2. oral and /or injectable immunizations; and
3. laboratory tests normally performed for a well child.
In order to be covered, Services shall be provided in accordance with prevailing medical standards consistent with
the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics, the U.S.
Preventive Services Task Force, or the Advisory Committee on Immunization Practices established under the
Public Health Service Act.
Expenses for these services are not subject to the Calendar Year Deductible, but are subject to the Coinsurance.
Covered Services 7-12
• Prosthetic Devices
The following Prosthetic Devices are covered when prescribed by a Physician:
1. artificial hands, arms, feet, legs and eyes, including permanent implanted lenses following cataract surgery;
2. appliances needed to effectively use artificial limbs or corrective braces;
3. penile prosthesis and surgery to insert penile prosthesis when necessary in the treatment of organic
impotence resulting from: treatment of prostate cancer, diabetes mellitus, peripheral neuropathy, medical
endocrine causes of impotence, arteriosclerosis /postoperative bilateral sympathectomy, spinal cord injury,
pelvic - perineal injury, post - prostatectomy, post - priapism, epispadias, and exstrophy.
Benefits may be provided for necessary replacement of a Prosthetic Device which is owned by the Covered Plan
Participant when due to irreparable damage, wear, or a change in the Covered Plan Participant's Condition, or when
necessitated due to growth of a child.
Covered Prosthetic Devices (except cardiac pacemakers and prosthetic devices incident to Mastectomy) are limited
to the first such permanent prosthesis (including the first temporary prosthesis if it is determined to be Medically
Necessary) prescribed for each specific Condition.
Exclusion:
1. Expenses for microprocessor controlled or myoelectric artificial limbs (e.g., C- legs); and
2. Expenses for cosmetic enhancements to artificial limbs.
• Skilled Nursing Facilities
The following Health Care Services may be Covered Services when: 1) the Covered Plan Participant is an inpatient
in a Skilled Nursing Facility; and 2) the Covered Plan Participant's Physician submits a treatment plan that is
acceptable to Wells Fargo Third Party Administrator and /or the Monroe County Group Health Plan Administrator
for coverage and payment purposes:
1. room and board;
2. respiratory, pulmonary, or inhalation therapy (e.g., oxygen)
3. drugs and medicines administered while an inpatient (except take -home drugs);
4. intravenous solutions;
5. administration of, including the cost of, whole blood and blood products;
6. dressings, including ordinary casts;
7. transfusion supplies and equipment;
8. diagnostic services, including radiology, ultrasound, laboratory, pathology and approved machine testing
(e.g., EKG);
9. chemotherapy treatment for proven malignant disease; and
10. Physical, Speech, and Occupational Therapy.
Exclusion — Expenses for an inpatient admission to a Skilled Nursing Facility for purposes of Custodial Care,
convalescent care, or any other service primarily for the convenience of the patient and /or his /her family members
or the Provider.
Covered Services 7-13
• Substance Dependency Care and Treatment
Care and treatment of Substance Dependency including:
Health Care Services (inpatient and outpatient or any combination thereon provided to a Covered Plan
Participant by a Physician or Psychologist in a program accredited by the Joint Commission of the
Accreditation of Healthcare Organizations or approved by the state of Florida for Detoxification or
Substance Dependency; and
2. Physician and Psychologist outpatient visits for the care and treatment of Substance Dependency.
• Surgical Assistant Services
Services rendered by a Physician, Registered Nurse First Assistant or Physician Assistant when acting as a surgical
assistant (provided no intern, resident, or other staff physician is available) when the assistant is necessary. The
Allowed Amount for such is limited to 20 percent of the surgical procedure's Allowed Amount.
• Surgical Procedures
Surgical procedures performed by a Physician including the following:
1. sterilization (tubal ligations and vasectomies), regardless of Medical Necessity;
2. surgery to correct deformity which was caused by disease, trauma, birth defects, growth defects or prior
therapeutic processes;
3. oral surgical procedures for excisions of tumors, cysts, abscesses, and lesions of the mouth;
4. surgical procedures involving bones or joints of the jaw (e.g., temporomandibular joint (TMJ) and facial
region if, under accepted medical standards, such surgery is necessary to treat Conditions caused by
congenital or developmental deformity, disease, or injury;
5. surgical procedures performed on a Covered Plan Participant for the treatment of Morbid Obesity (e.g.,
intestinal bypass, stomach stapling, balloon dilation) and the associated care provided the Covered Plan
Participant meets all of the following criteria:
• the Covered Plan Participant has not previously undergone the same or similar procedure in the
lifetime of the Plan;
• before proceeding with a gastric procedure, the Covered Plan Participant shall be actively engaged in
a disease management program for obesity for a minimum of six (6) months. This program must be
supervised by a Physician and include nutrition and exercise, including dietitian consultation, low
calorie diet, increase physical activity and behavioral modification. This program must be
documented in a medical record that includes: 1) regular monthly Physician visits; 2) participation in
nutrition and exercise programs that are supervised by a Physician working in cooperation with
dietitians and /or nutritionists; and 3) healthy activity with supervised exercise three (3) to five (5)
times a week;
• the Covered Plan Participant must enter a dedicated bariatric program with dietary /nutrition and
psychological /psychiatric preoperative evaluation and the program must address long -term lifestyle
management;
Covered Services 7-14
the need for surgery must be documented by a Physician other than the surgeon for the bariatric
procedure;
Morbid Obesity must have existed for five (5) years prior to surgical consideration and documented
by Physician records;
weight loss dietary and exercise program must occur for a minimum of six (6) months or longer
prior to surgery, must be within the two (2) years prior to surgery and must be documented in a
medical record, not a summary letter from the Physician.
If the Covered Plan Participant fails to achieve a 10% reduction in BMI, he /she may be eligible for surgery
if BMI >35 with co- morbidities or BMI >40.
Exclusion — Surgical procedures for the treatment of Morbid Obesity including: intestinal bypass, stomach
stapling, balloon dilation and associate care for the surgical treatment of Morbid Obesity, if the Covered
Plan Participant has previously undergone the same or similar procedures in the lifetime of the Plan.
Surgical procedures performed to revise, or correct defects related to the surgical procedures, including but
not limited to a prior intestinal bypass. stomach stapling or balloon dilation are also excluded.
6. services of a Physician for the purpose of rendering a second surgical opinion and related diagnostic services
to help determine the need for surgery.
Reimbursement Guidelines for Surgical Procedures
• Reimbursement for multiple surgical procedures performed in addition to the primary surgical procedure,
on the same or different areas of the body, during the same operative session will be based on 50 percent of
the Allowed Amount for any secondary surgical procedure(s) performed and the Coinsurance indicated in
the Covered Plan Participant's Schedule of Benefits. This guideline is applicable to all bilateral procedures
and all surgical procedures performed on the same date of service;
• Reimbursement for Incidental Surgical Procedures is limited to the Allowed Amount for the primary
procedure, and there is no additional payment for any incidental procedure. An "Incidental Surgical
Procedure" is defined as a surgery where one, or more than one, surgical procedure is performed through
the same incision or operative approach as the primary surgical procedure which, in the opinion of Wells
Fargo TPA and /or the Monroe County Group Health Plan Administrator, is not clearly identified and /or
do not add significant time or complexity to the surgical session. For example, the removal of a normal
appendix performed in the conjunction with a Medically Necessary hysterectomy is an Incidental Surgical
Procedure (i.e., there is no reimbursement for the removal of the normal appendix in the example); and
• Reimbursement for surgical procedures for fracture care, dislocation treatment, debridement, wound repair,
unna boot, and other related Health Care Services, is included in the Allowed Amount of the surgical
procedure.
• Transplant Services
Limited to the procedures listed below, if coverage has been predetermined by Wells Fargo Third Party
Administrator and the Monroe County Group Health Plan Administrator, subject to the conditions and limitations
described below.
Transplant includes pre - transplant, transplant and post- discharge services, and treatment of complications after
transplantation. Benefits will only be paid for services, care and treatment received or in connection with a:
Covered Services 7-15
Bone Marrow Transplant which is specifically listed in the rule 5913- 12.001 of the Florida Administative Code
or any successor or similar rule or covered by Medicare as described in the most recent published Medicare
Coverage Issues Manual issued by the Center for Medicare and Medicaid Services. Coverage will be
provided for the expenses incurred for the donation of bone marrow by a donor to the same extent such
expenses would be covered for a Covered Plan Participant and will be subject to the same limitations and
exclusions as would be applicable to a Covered Plan Participant. Covered expenses include the reasonable
expenses of searching among immediate family members and donors identified through the National Bone
Marrow Donor Program;
2. corneal transplant;
3. heart transplant (including a ventricular assist device, if indicated, when used as a bridge to heart
transplantation);
4. heart -lung combination transplant;
5. liver transplant;
6. kidney transplant;
7. pancreas transplant;
8. pancreas transplant performed simultaneously with a kidney transplant, or
9. lung -whole single or whole bilateral transplant.
In order to ensure that a proposed transplant is covered, the Covered Plan Participant or the Covered Plan
Participant's Physician should notify Wells Fargo TPA in advance of the Covered Plan Participant's initial
evaluation for the procedure. Corneal and kidney transplants do not require prior benefit determination.
Wells Fargo TPA and /or the Monroe County Group Health Plan Administrator will make a prior benefit
determination concerning the proposed transplant, however, Wells Fargo TPA must be given the opportunity to
evaluate the clinical results of the Covered Plan Participant's initial evaluation for the transplant as well as any
applicable protocols. If Wells Fargo TPA is not given an opportunity to make the prior benefit determination, the
transplant may be subject to a reduction in payment in accordance with the rules set forth in the Benefits Utilization
Management/ Utilization Review Programs Section. Once coverage for the transplant is predetermined, Wells
Fargo TPA will advise the Covered Plan Participant or the Covered Plan Participant's Physician of the coverage
decision.
For covered transplants, and all related complications, the Plan will cover:
• Hospital and Physician expenses provided that such services will be paid in accordance with the same terms
and conditions for care and treatment of any other covered Condition.
• Donor costs and organ acquisition for transplants, other than Bone Marrow Transplants, provided such
costs are not covered in whole or in part by any other insurance carrier, organization or person other than
the donor's family or estate.
Covered Plan Participants may call the Wells Fargo TPA Customer Service telephone number indicated in the
Monroe County Group Health Plan Document or on the Covered Plan Participant's Identification Card in order to
determine which Bone Marrow Transplants are covered under the Monroe County Group Health Plan Document.
Covered Services 7-16
Exclusion
Expenses for the following are excluded:
1. transplant procedures not included in the list above, or otherwise excluded under the Monroe County
Group Health Plan Document (e.g., Experimental or Investigational transplant procedures);
2. transplant procedures involving the transplantation or implantation or 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 the Monroe County Group Health Plan Document;
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 which is not specifically listed in rule 59- B- 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 the
Covered Plan Participant and /or the Covered Plan Participant's family to and from the approved facilit\-;
and
9. any artificial heart or mechanical device that replaces either the atrium and /or the ventricle.
Covered Services 7-17
SECTION 8 - GENERAL EXCLUSIONS
Introduction
The Monroe County Group Health Plan Document expressly excludes expenses for the following Health Care
Services, supplies, drugs or charges. The following exclusions are in addition to any exclusions specified in the
Covered Services Section or any other section of the Monroe County Group Health Plan Document.
• Adult Wellness preventive care or routine screening Services, except as specified under the Benefit
Maximums section in the Schedule of Benefits.
• Arch Supports shoe inserts designed to effect conformational changes in the foot or foot alignment,
orthopedic shoes, over -the- counter, custom -made or built -up shoes, cast shoes, sneakers, ready -made
compression hose or support hose, or similar type devices /appliances regardless or intended use, except for
therapeutic shoes (including inserts and /or modifications) for the treatment of severe diabetic foot disease.
• Assisted Reproductive Therapy (Infertility) including, but not limited to, associated Services, supplies,
and medications for In Vitro Fertilization (IVF); Gamete Intrafallopian Transfer (GIFT) procedures; Zygote
Intrafallopian Transfer (ZIFT) procedures; Artificial Insemination (AI); embryo transport; surrogate
parenting, donor semen and related costs including collection and preparation; and infertility treatment
medication.
• Autopsy or postmortem examination services, unless specifically requested by Wells Fargo Third Party
Administrator.
• Complementary or Alternative Medicine including, but not limited to, self -care or self -help training;
homeopathic medicine and counseling; Ayurvedic medicine such as lifestyle modifications and purifications
therapies; traditional Oriental medicine including naturopathic medicine; environmental medicine including
the field of clinical ecology; chelation therapy; thermography; mind -body interactions such as meditation,
imagery, yoga, dance, and art therapy; biofeedback; prayer and mental healing; manual healing methods such
as the Alexander technique, aromatherapy, Ayurvedic massage, craniosacral balancing, Feldenkrais method,
Hellerwork, polarity therapy, Reichian therapy, reflexology, rolfing, shiatsu, traditional Chinese massage,
Trager therapy, trigger -point myotherapy, and biofield therapeutics; Reiki, SHEN therapy, and therapeutic
touch; bioelectromagnetic applications in medicine; and herbal therapies.
• Complications of Non - Covered Services including the diagnosis or treatment of any Condition which is a
complication of a non - covered Health Care Service (e.g., Health Care Services to treat a complication of
cosmetic surgery are not covered).
• Contraceptive medications, devices, appliances, or other Health Care Services when provided for
contraception.
General Exclusions 8-1
• Cosmetic Services, including any Service to improve the appearance or self - perception of an individual
(except as covered under the Breast Reconstructive Surgery category), including and without limitation:
cosmetic surgery and procedures or supplies to correct hair loss or skin wrinkling (e.g., Minoxidil, Rogaine,
Retin -A), and hair implants /transplants.
• Costs related to telephone consultations, failure to keep a scheduled appointment, or completion of any
form and /or medical information.
• Custodial Care and any service of a custodial nature, including and without limitation: Health Care
Services primarily to assist in the activities of daily living; rest homes; home companions or sitters; home
parents; domestic maid services; respite care; and provision of services which are for the sole purposes of
allowing a family member or caregiver of a Covered Plan Participant to return to work.
• Dental Care or treatment of the teeth or their supporting structures or gums, or dental procedures,
including but not limited to: extraction of teeth, except as covered under the "Dental" Covered Services
subsection; restoration of teeth with or without fillings, crowns or other materials, bridges, cleaning of teeth,
dental implants, dentures, periodontal or endodontic procedures, orthodontic treatment (e.g., braces),
intraoral prosthetic devices, palatal expansion devices, bruxism appliances, and dental x -rays, except as
covered under the "Dental" Covered Services subsection. This exclusion does not apply to TMJ, wisdom
tooth extraction, an Accidental Dental Injury and the Child Cleft Lip and Cleft Palate Treatment Services as
described in the Covered Services Section.
• Diabetic Equipment and Supplies used for the treatment of diabetes which are otherwise covered under
the Pharmacy Program.
• Drugs
Prescribed for uses other than the Food and Drug Administration (FDA) approved label indications. This
exclusion does not apply to any drug that has been proven safe, effective and accepted for the treatment of
the specific medical Condition for which the drug has been prescribed, as evidenced by the results of good
quality controlled clinical studies published in at least two or more peer- reviewed full length articles in
respected national professional medical journals. This exclusion also does not apply to any drug prescribed
for the treatment of cancer that has been approved by the FDA for at least one indication, provided the
drug is recognized for treatment of the Covered Plan Participant's particular cancer in a Standard
Reference Compendium or recommended for treatment of a Covered Plan Participant's particular cancer
in Medical Literature. Drugs prescribed for the treatment of cancer that have not been approved for any
indication are excluded.
2. Any non - Prescription medicines, remedies, vaccines, biological products (except insulin), pharmaceuticals
or chemical compounds, vitamins, mineral supplements, fluoride products, over -the- counter drugs,
products, or health foods.
3. Any drug which is indicated or used for sexual dysfunction (e.g., Cialis, Viagra) (except when drugs are
being used for Medically Necessary treatment of organic impotence resulting from: treatment of prostate
cancer, diabetes mellitus, peripheral neuropathy, medical endocrine causes of impotence,
General Exclusions 8-2
arteriosclerosis /postoperative bilateral sympathectomy, spinal cord injury, pelvic - perineal injury, post -
prostatectomy, post - priapism, epispadias, and exstrophy). The exception described in exclusion number
one above does not apply to sexual dysfunction drugs excluded under this paragraph.
• Experimental or Investigational Services except as otherwise covered under the Bone Marrow
Transplant provision of the Transplant Services subsection.
• Food and Food Products prescribed or not, except as covered in the Enteral Formulas subsection of the
"Covered Services" section.
• Foot Care which is routine, including any Health Care Service, in the absence of disease. This exclusion
includes, but is not limited to: non - surgical treatment of bunions; flat feet; fallen arches; chronic foot strain;
trimming of toenails corns, or calluses.
General Exclusions include, but are not limited to:
1. any Health Care Service received prior to a Covered Plan Participant's Effective Date or after the date the
Covered Plan Participant's coverage terminates;
2. any Service to diagnose or treat any Condition resulting from or in connection with a Covered Plan
Participant's job or employment;
3. any Health Care Services not within the service subsections described in the "Covered Services" section,
any rider, or Endorsement attached hereto, unless such services are specifically required to be covered by
applicable law;
4. any Health Care Services provided by a Physician or other health care Provider related to a Covered Plan
Participant by blood and marriage;
5. any Health Care Services which is not Medically Necessary as determined by Wells Fargo TPAand /or
KPHA and defined in the Monroe County Group Health Plan Document. The ordering of a Service by a
health care Provider does not in itself make such Service Medically Necessary or a Covered Service;
6. any Health Care Service rendered at no charge;
7. expenses for claims denied because information requested was not received from a Covered Plan
Participant regarding whether or not they have other coverage and the details of such coverage;
8. any Health Care Services to diagnose or treat a Condition which, directly or indirectly, resulted from or is
in connection with:
a) war or an act of war; whether declared or not;
b) a Covered Plan Participants participation in, or commission of, any act punishable by law
as a misdemeanor or felony, or which constitutes riot, or rebellion;
c) a Covered Plan Participant engaging in an illegal occupation;
d) Services received at military or government facilities; or
General Exclusions 8-3
e) Services received to treat a Condition arising out of a Covered Plan Participants service in
the armed forces, reserves and /or National Guard;
Services that are not patient- specific, as determined solely by the Plan
9. Health Care Services rendered because they were ordered by a court, unless such Services are Covered
Services under the Monroe County Group Health Plan Document.
10. any Health Care Services rendered by or through a medical or dental department maintained by or on
behalf of an employer, mutual association, labor union, trust, or similar person or group; or
11. Health Care Services that are not direct, hands -on, and patient specific, including, but not limited to the
oversight of a medical laboratory to assure timeliness, reliability, and /or usefulness of test results, or the
oversight of the calibration of laboratory machines, equipment, or laboratory technicians.
• Genetic Screening including the evaluation of genes of a Covered Plan Participant to determine if they are
carriers of an abnormal gene that puts them at risk for a disease.
• Hearing aids (external or implantable aids) and Services related to the fitting or provision of hearing aids,
including tinnitus maskers, batteries, and cost of repair; and routine hearing Tests or Services necessary due
to degenerative hearing loss not specifically caused by sickness, congenital defect or trauma.
• Immunizations except those covered under the Preventive Child Health Supervision Services or Adult
Wellness Services subsections of the "Covered Services" section.
• Maternity Services rendered to a Covered Plan Participant who becomes pregnant as a Gestational
Surrogate under the terms of, and in accordance with, a Gestational Surrogacy Contract or Arrangement.
This exclusion applies to all expenses for prenatal, intra - partal, and post - partal Maternity/ Obstetrical Care,
and Health Care Services rendered to the Covered Plan Participant acting as a Gestational Surrogate.
For the definition of Gestational Surrogate and Gestational Surrogacy Contract see the Definitions section
of the Monroe County Employee Group Health Plan Document.
• Oral Surgery except as provided under the "Covered Services" section.
• Orthomolecular Therapy including nutrients, vitamins, and food supplements.
• Oversight of a medical laboratory by a Physician or other health care Provider. "Oversight" as used in
this exclusion shall include, but is not limited to, the oversight of-
1. the laboratory to assure timeliness, reliability, and /or usefulness of test results;
2. the calibration of laboratory machine or testing of laboratory equipment;
General Exclusions 8-4
3. the preparation, review or updating of any protocol or procedure created or reviewed by a Physician or
other health care Provider in connection with the operation of the laboratory; and
4. laboratory equipment or laboratory personnel for any reason.
• Personal Comfort, Hygiene or Convenience Items and Services deemed to be not Medically Necessary
and not directly related to the Covered Plan Participant's treatment including, but not limited to:
1. beauty and barber services;
2. clothing including support hose;
3. radio and television;
4. guest meals and accommodations
5. telephone charges;
6. take -home supplies;
7. travel expenses (other that Medically Necessary Ambulance Services);
8. motel /hotel accommodations;
9. air conditioners, furnaces, air filters, air or water purification systems, water softening systems, humidifiers,
dehumidifiers, vacuum cleaners or any other similar equipment and devices used for environmental control
or to enhance an environmental setting;
10. hot tubs, Jacuzzis, heated spas; pools; or memberships to health clubs;
11. heating pads, hot water bottles, or ice packs;
12. physical fitness equipment;
13. hand rails and grab bars; and
14. Massages except as covered in the "Covered Services" section of the Monroe County Group Health Plan
Document.
• Prescription Drug Copayments, Coinsurance and Deductibles (if any), or any part thereof, the Covered
Plan Participant is obligated to pay under the Prescription Drug Program.
• Rehabilitative Therapies provided on an inpatient or outpatient basis, except as provided in the Hospital,
Inpatient Rehabilitation, Skilled Nursing Facility, Home Health Care, and Outpatient Cardiac, Occupational,
Physical, Speech, and Spinal Manipulations subsections of the "Covered Services" section. Rehabilitative
Therapies provided for the purpose of maintaining rather than improving the Covered Plan Participant's
Condition are also excluded.
• 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.
General Exclusions 8-5
• Sports - Related devices and services used to affect performance primarily in sports - related activities; all
expenses related to physical conditioning programs such as athletic training, bodybuilding, exercise, fitness,
flexibility, and diversion or general motivation.
• Training and Educational Programs, or materials, including; but not limited to programs or materials for
pain management and vocational rehabilitation, except as provided under the Diabetes Outpatient Self
Management subsection of the "Covered Services" section.
• Travel or vacation expenses even if prescribed or ordered by a Provider.
• Volunteer Services or Services which would normally be provided free of charge and any charges
associated with Deductible, Coinsurance, or Copayments (if applicable) requirements which are waived by a
health care Provider.
• Weight Control Services including any Service to lose, gain, or maintain weight regardless of the reason
for the Service or whether the Service is part of a treatment plan for a Condition. This exclusion includes,
but is not limited to, weight control /loss programs, appetite suppressants and other medications; dietary
regimens; food or food supplements; exercise programs; exercise or other equipment.
• Wigs and /or cranial prosthesis.
General Exclusions 8-6
SECTION 9 - ELIGIBILITY FOR COVERAGE
Each employee or other individual who is eligible to participate in the Plan, and who meets and continues to meet
the eligibility requirements described in the Monroe County Group Health Plan Document, shall be entitled to
apply for coverage under the Plan. These eligibility requirements are binding upon Covered Plan Participants and
their eligible family members. No changes in the eligibility requirements will be permitted except as permitted by
the Monroe County Group Health Plan Administrator. Acceptable documentation may be required as proof that
an individual meets and continues to meet the eligibility requirements such as a court order naming the Eligible
Employee as the legal guardian or appropriate adoption documentation described in the "Enrollment and Effective
Date of Coverage" section.
Eligibility Requirements for Covered Employee
In order to be eligible to enroll as a Covered Employee, an individual must be an Eligible Employee. An Eligible
Employee must meet each of the following requirements:
• The employee must be a bona fide employee of a Monroe County Employer participating in the Monroe
County Group Health Plan;
• The employee must be actively working 25 hours or more per week on a regular basis;
• The employee must have completed the applicable waiting period of 60 days of continuous service (Waiting
Period);
• The employee must meet any additional eligibility requirement(s) required by the Monroe County Group
Health Plan Administrator.
Employees and qualified Dependents are eligible for coverage on the day following the 60th day of continuous
service or Waiting Period.
Eligibility Requirements for Covered Retirees
An individual who meets the eligibility criteria specified below is an Eligible Retiree and is eligible to apply for
coverage under this Monroe County Group Health Plan Document:
• A person who elects to continue or re- enroll in the Monroe County Group Health Plan at the time of their
official retirement under the Florida Retirement System (FRS) and if not currently an Eligible Employee,
that Monroe County was their last FRS employer prior to retirement. If the Eligible Retiree fails to elect
retiree coverage at time of retirement, waives retiree coverage or lets coverage lapse, the Eligible Retiree will
permanently lose entitlement to enroll under the Monroe County Group Health Plan.
AND
• meets one of the following requirements as established by the Board of County Commissioners Resolution
No. 354 -2003 — Retirement Eligibility Requirements for Group Health Insurance Coverage for Monroe
County Employees:
Eligibility for Coverage 9-1
1. Hire date prior to 10/01/01; a minimum of ten (10) years of full -time service with Monroe County;
retire under the FRS on, or after, the Normal Retirement date as described in Section 121.021 (29),
F.S.; and covered under the Plan at retirement. Current contribution is HIS* for 10 years of service
with FRS.
2. Hire date prior to 10/01/01; a minimum of ten (10) years of full-time service with Monroe County;
retire under the FRS at an Early Retirement date as described in Section 121.021 (30), F.S.; covered
under the Plan at retirement; 60 years of age or age and years of service must satisfy Rule of 70 ** at
time of retirement. Current contribution is HIS* for 10 years of service with FRS.
3. Hire date prior to 10/01/01; a minimum of ten (10) years of full-time service with Monroe County;
retire under the FRS at an Early Retirement date as described in Section 121.021 (30), F.S.; covered
under the Plan upon retirement; NOT 60 years of age and age and years of service do not satisfy Rule
of 70 * *. Current contribution is the departmental rate. Upon attaining either the age of 60 or satisfy_
Rule of 70 ** the contribution will change to the HIS* for 10 years of service with FRS.
4. Hire date on or after 10/01/01; a minimum of ten (10) years of full -time service with Monroe
County; retire with the FRS as described in Section 121.021 (29) or 121.021 (30), F.S.; covered under
the Plan upon retirement. Current contribution is the departmental rate.
5. Retire from FRS as described in Section 121.021 (29) or 121.021 (30), F.S.; less than ten (10) years of
full -time service with Monroe County; covered under the Plan upon retirement. Current contribution
is the departmental rate.
6. Former Eligible Employee with at least ten (10) years of full -time service with Monroe County;
covered under the Plan upon termination of employment and fully vested under FRS who elected
not to retire under FRS upon termination of employment with Monroe County, may elect to re- enroll
under the Plan upon retirement under FRS, provided that Monroe County was their last FRS
employer. Current contribution is the departmental rate.
*HIS - Health Insurance Subsidy per Section 112.363, Florida Statutes.
* *Rule of 70 — Eligible Retirees satisfy the Rule of 70 if their age, combined with the number of years of
service with Monroe County totals 70 or more.
Eligibility Requirements for Dependent(s)
An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible to apply for
coverage under the Plan:
1. The Covered Employee /Retiree's spouse under a legally valid existing marriage or Registered
Domestic Partner;
2. A Covered Employee /Retiree's child, provided the child is under the age 19 and unmarried, except
as provided below.
3. The Covered Employee /Retiree's child who:
a. is under the age of 25 or is still within the Calendar Year in which he or she reaches age 25 (or in the
case of a Foster Child, is no longer eligible under the Foster Child Program), and:
i. is dependent upon the Covered Employee /Retiree for financial support; and
Eligibility for Coverage 9-2
ii. is living in the household of the Covered Employee /Retiree or is a full -time or part -time
student; or
b. is under the age of 30 or is still within the Calendar Year in which he or she reaches age 30 and who:
i. is unmarried and does not have a dependent;
ii. is a Florida resident or a full -time or part -time student;
ill. is not enrolled in any other health coverage policy or plan;
iv. is not entitled to benefits under Title XVII of the Social Security Act; and
v. when:
1. enrolling for the first time under the Covered Employee /Retiree's policy after age
25; or
2. re- enrolling after the end of the Calendar Year in which the child reaches the age of
25, with no gap in Creditable Coverage longer than 63 days.
c. in the case of a handicapped dependent child, such child is eligible to continue coverage, beyond the
limiting age of 30, as a Covered Dependent if the dependent child is:
i. otherwise eligible for coverage under the Plan;
ii. incapable of self - sustaining employment by reason of mental retardation or physical
handicap; and
ill. chiefly dependent upon the Covered Employee /Retiree for support and maintenance
provided that the symptoms or causes of the child's handicap existed prior to the
child's 30th 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.
or
2. The newborn child of a Covered Dependent child who has not reached the end of the Calendar Year in
which he or she becomes 25. Coverage for such newborn child will automatically terminate 18 months after
the birth of the newborn child.
As used in this Plan, the term "child" or "children" means:
1. Natural children;
2. Legally adopted children;
3. Children placed in your home for adoption pursuant to Chapter 23, Florida Statutes;
4. Stepchildren you are eligible to claim as dependents on your current federal tax return;
5. Foster children for whom you have been granted court- ordered temporary custody or other custody;
6. Children for whom you are legal guardian or have court- ordered temporary custody or other custody.
Note: If a Covered Dependent child who has reached the end of the Calendar Year in which he or she becomes
25, obtains a dependent of their own (e.g., through birth or adoption), such newborn child will not be eligible for
this coverage and the Covered Dependent child will also lose his or her eligibility for this coverage. It is the
Covered Employee's sole responsibility to establish that a child meets the applicable requirements for eligibility.
Eligibility will terminate on the last day of the month in which the child no longer meets the eligibility criteria
required to be an Eligible Dependent.
Eligibility for Coverage 9-3
SECTION 10 - ENROLLMENT AND EFFECTIVE DATE OF COVERAGE
Eligible Employees /Eligible Retirees and Eligible Dependents may enroll for coverage according to the provisions
below.
Any Eligible Employee /Eligible Retiree or Eligible Dependent who is not properly enrolled will not be covered
under the Monroe County Group Health Plan Document. Neither Wells Fargo TPA nor the Monroe County
Group Health Plan Administrator will have any obligation whatsoever to any individual who is not properly
enrolled.
The Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. No. 110 -173) requires Group Health Plans to
share eligibility information pertaining to all Covered Plan Participants with the Centers for Medicare and Medicaid
Services (CMS). This law was enacted to enable Group Health Plans and Medicare to more accurately identify
those Participants enrolled in both the Plan and Medicare coverage and to expedite the appropriate coordination of
benefits. In accordance with this requirement, complete eligibility information (including Dependent Social Security
numbers) will be required at the time of enrollment in the Plan.
Any Employee /Retiree or Eligible Dependent who is eligible for coverage under the Monroe County Group Health
Plan Document may apply for coverage according to the provisions set forth below.
Enrollment Forms /Electing Coverage
To apply for coverage, the Eligible Employee /Retiree must:
1. complete and submit, through the Plan Administrator (Benefits Office), the Enrollment Form;
2. provide any additional information needed to determine eligibility, at the request of Wells Fargo TPA or the
Monroe County Group Health Plan Administrator;
3. pay any required contribution; and
4. complete and submit through the Monroe County Health Plan Administrator (Benefits Office), an
Enrollment Form to add Eligible Dependents.
When making application for coverage, the Eligible Employee /Retiree must elect one of the types of coverage
available under the Plan's program. Such types may include:
Employee/ Retiree Only Coverage — This type of coverage provides coverage for the Covered Employee /Retiree
only.
Employee /Retiree & Spouse Coverage — This type of coverage provides coverage for the Covered
Employee /Retiree and their spouse under a legally valid existing marriage or Registered Domestic Partner.
Employee /Retiree & Child(ren) Coverage — This type of coverage provides coverage for the Covered
Employee /Retiree and their covered child(ren) only.
Employee /Retiree & Family Coverage — This type of coverage provides coverage for the Covered
Employee /Retiree and their Covered Dependents.
Enrollment and Effective Date of Coverage 10-1
Contribution amounts are based on the type of coverage selected. These contributions amounts are set by the
Monroe County Board of County Commissioners.
Enrollment Periods
The enrollment periods for applying for coverage are as follows:
Initial Enrollment Period is the period of time during which Eligible Employees are first eligible to enroll their
Eligible Dependents. It starts on the Eligible Employee's initial date of hire and ends no less than 30 days later.
Annual Open Enrollment Period is the period of time during which Eligible Employees and Eligible Retirees are
given the opportunity to select coverage from among the alternatives included in the Plan's program. The period is
established by the Monroe County Group Health Plan Administrator, occurs annually, and will take place when
specified by Monroe County Group Health Plan Administrator.
Special Enrollment Period is the 30 -day period of time immediately following a special circumstance during
which an Eligible Retiree or Eligible Dependent may enroll for coverage. Special circumstances are described in the
Special Enrollment Period subsection.
Employee Enrollment
All Eligible Employees will complete an Enrollment Form at time of hire and are enrolled in the Monroe County
Group Health Plan (regardless of other coverage). The Effective Date will be the date specified by the Monroe
County Group Health Plan Administrator (Benefits Office).
Annual Open Enrollment Period
During an Annual Open Enrollment Period Eligible Dependents (except special rules apply to Eligible Dependent
child(ren) who have reached the end of the Calendar Year in which they become 25) who were not enrolled in the
Plan during the Initial Enrollment Period or a Special Enrollment Period may be enrolled in the Plan. Eligible
Employees and Eligible Retirees may also make coverage changes during this time. The effective date of coverage
will be the date established by the Monroe County Group Health Plan Administrator.
Eligible Employees and Eligible Retirees who do not make changes to their coverage selection, during the Annual
Open Enrollment Period will retain the coverage in effect unless the Eligible Retiree or the Eligible Dependent has
a new opportunity to enroll due to a special circumstance as outlined in the Special Enrollment Period subsection of
this section.
Note: The Annual Open Enrollment Period will only apply to Eligible Dependent child(ren) who have reached the
end of the Calendar Year in which they become 25, but who have not reached the end of the Calendar Year in
which they become 30, if the Eligible Dependent child(ren) had other Creditable Coverage, lost such Creditable
Coverage and applied for coverage under this policy within 63 days of the loss of the prior Creditable Coverage.
Enrollment and Effective Date of Coverage 10-2
Special Enrollment Period
An Eligible Retiree and /or Eligible Dependents may apply for coverage as a result of a special enrollment event.
To apply for coverage, the Eligible Retiree and /or Eligible Dependents must complete the applicable Enrollment
Form and forward it to the Monroe County Group Health Plan Administrator (Benefits Office) within 30 days of
the date of the special enrollment event.
For the purposes of the Monroe County Group Health Plan Document, the following are the special enrollment
events:
Eligible Dependents who lose their coverage under another group health benefit plan, or coverage under
other health insurance, or COBRA continuation coverage that the Eligible Dependent was covered under at
the time of initial enrollment provided the loss of other coverage under a group health plan or health
insurance coverage was a result of termination of employment, reduction in the number of hours worked,
reaching or exceeding the maximum lifetime of all benefits under other health coverage, the employer
ceased offering group health coverage, death of a spouse, divorce, legal separation or employer
contributions toward such coverage was terminated.
Note: Loss of coverage for failure to pay any required contribution /premium on a timely basis or for cause
(such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the
prior health coverage) is not a qualifying event for special enrollment.
2. Eligible Employee /Retiree obtains an Eligible Dependent through marriage, established Domestic
Partnership, birth, adoption or placement in anticipation of adoption.
3. Former Eligible Employee with at least ten (10) years of full -time service with Monroe County;
covered under the Plan upon termination of employment and fully vested under FRS who elected not to
retire under FRS upon termination of employment with Monroe County, must re- enroll under the Plan
within 30 days of retirement under FRS, provided that Monroe County was their last FRS employer.
4. Pursuant to the Children's Health Insurance Program Reauthorization Act of 2009, a Dependent shall
become eligible for enrollment under the Plan following the loss of the Dependent's eligibility for
Participation in state Medicaid or Children's Health Insurance Program (CHIP) coverage. Following such a
loss of eligibility, a Dependent special enrollment period shall commence on the date the Dependent loses
eligibility for Medicaid or CHIP coverage or on the date the Dependent or Employee becomes eligible
becomes eligible for premium assistance subsidy under Medicaid or CHIP. In accordance with federal law,
this Dependent special enrollment period shall continue for a period of not less than sixty (60) days. (This is
an exception to the previously stated thirty (30) day enrollment period allotted for other types of Dependent
special enrollment qualifying events.)
The Effective Date of coverage as a result of a special enrollment event is the date of the special enrollment event
(e.g., date of birth, date of marriage). Eligible Dependents who do not enroll 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 enrollment of Eligible Dependents of a Covered Plan Participant).
Note: The Special Enrollment Period will only apply to Eligible Dependent child(ren) who have reached the end
of the Calendar Year in which they become 25, but who have not reached the end of the Calendar Year in which
they become 30, if the Eligible Dependent child(ren) had other Creditable Coverage, lost such Creditable Coverage
and applied for coverage under this policy within 63 days of the loss of the prior Creditable Coverage.
Enrollment and Effective Date of Coverage 10-3
Dependent Enrollment
An individual may be added upon becoming an Eligible Dependent of a Covered Employee /Retiree. Below are
special rules for certain Eligible Dependents.
Newborn Child — To enroll a newborn child who is an Eligible Dependent, the Covered Employee /Retiree must
submit an Enrollment Form to the Monroe County Group Health Plan Administrator (Benefits Office) during the
30 -day period immediately following the date of birth. The Effective Date of coverage for the newborn child will
be the date of birth.
If timely notice is given, no additional contribution will be charged for coverage of the newborn child for not less
than 30 days after the birth of the child. If timely notice is not received, the applicable contribution will be charged
from the date of birth. The applicable contribution for the child will be charged after the initial 30 -day period in
either case. Coverage will not be denied for a newborn child of the Covered Employee provides notice to the
Monroe County Group Health Plan Administrator (Benefits Office) and an Enrollment Form is received within the
60 -day period following the birth of the child and any applicable contribution is paid back to the date of birth.
If the newborn is not enrolled within sixty days of the date of birth, the newborn child will not be covered, and may
only be enrolled under the Monroe County Group Health Plan Document during an Annual Open Enrollment
Period, or in the case of a Special Enrollment event, during the Special Enrollment Period.
Note: Coverage for a newborn child of a Covered Dependent child who has not reached the end of the Calendar
Year in which he or she becomes 25 will automatically terminate 18 months after the birth of the newborn child.
For a Covered Dependent child who has reached the end of the Calendar Year in which he or she becomes 25, if
the Covered Dependent child obtains a dependent of their own (e.g., through birth or adoption), such newborn
child will not be eligible for this coverage and cannot enroll. Further, the Covered Dependent child will also lose
his or her eligibility for this coverage.
Adopted Newborn Child — To enroll an adopted newborn child, the Covered Employee /Retiree must submit an
Enrollment Form through the Monroe County Group Health Plan Administrator (Benefits Office) during the 30-
day period immediately following the date of birth. The Effective Date of coverage for an adopted newborn child,
eligible for coverage, will be the moment of birth, provided that a written agreement to adopt such child has been
entered into by the Covered Employee /Retiree prior to the birth of such child, whether or not such an agreement is
enforceable. The Covered Employee /Retiree may be required to provide any information and /or documents that
are deemed necessary in order to administer this provision.
If timely notice is given, no additional contribution will be charged for coverage of the adopted newborn child for
not less than 30 days after the birth of the child. If timely notice is not received, the applicable contribution will be
charged from the date of birth. The applicable contribution for the child will be charged after the initial 30 -day
period in either case. Coverage will not be denied for an adopted newborn child if the Covered Employee /Retiree
provides notice to the Monroe County Group Health Plan Administrator (Benefits Office) and an Enrollment
Form is received within the 60 -day period following the birth of the adopted newborn child and any applicable
contribution is paid back to the date of birth.
If the adopted newborn child is not enrolled within sixty days of the date of birth, the adopted newborn child will
not be covered, and may only be enrolled under the Monroe County Group Health Plan Document during an
Annual Open Enrollment Period, or in the case of a Special Enrollment event, during the Special Enrollment
Period.
Enrollment and Effective Date of Coverage 10-4
If the adopted newborn child is not ultimately placed in the residence of the Covered Employee /Retiree, there shall
be no coverage for the adopted newborn child. It is the responsibility of the Covered Employee /Retiree to notify
the Monroe County Group Health Plan Administrator within ten calendar days of the date that placement was to
occur if the adopted newborn child is not placed in the residence.
Adopted /Foster Children — To enroll an adopted or Foster Child, other than a newborn child, the Covered
Employee /Retiree must submit an Enrollment Form during the 30 -day period immediately following the date of
placement. The Effective Date for an adopted or Foster child (other than an adopted newborn child) will be the
date such adopted or Foster child is placed in the residence of the Covered Employee /Retiree in compliance with
applicable law. Any Pre - existing Condition exclusionary period will not apply to an adopted child but will apply to a
Foster child. The Covered Employee /Retiree may be required to provide any information and /or documents
deemed necessary in order to properly administer this section.
In the event the Monroe County Group Health Plan Administrator is not notified within 30 days of the date of
placement, the child will be added as of the date of placement so long as the Covered Employee /Retiree provides
notice to the Monroe County Group Health Plan Administrator, and the Benefits Office receives the Enrollment
Form within 60 days of the placement. If the adopted or Foster Child is not enrolled within sixty days of the date
of placement, the adopted or Foster child will not be covered, and may only be enrolled under the Monroe County
Group Health Plan Document during an Annual Open Enrollment Period, or in the case of a Special Enrollment
event, during the Special Enrollment Period. For all children covered as adopted children, if the final decree of
adoption is not issued, coverage shall not be continued for the proposed adopted Child. Proof of final adoption
must be submitted to the Monroe County Group Health Plan Administrator (Benefits Office). It is the
responsibility of the Covered Employee /Retiree to notify the Monroe County Group Health Plan Administrator if
the adoption does not take place. Upon receipt of this notification, coverage for the child will be terminated as of
the Effective Date of the adopted child upon receipt of the written notice.
If the Covered Employee /Retiree's status as a foster parent is terminated, coverage will end for any Foster Child. It
is the responsibility of the Covered Employee /Retiree to notify the Monroe County Group Health Plan
Administrator that the Foster Child is no longer in the Covered Employee /Retiree's care. Upon receipt of this
notification, coverage for the child will be terminated on the date of the Covered Employee /Retiree's status as a
foster parent terminated.
Marital Status — The Covered Employee /Retiree may apply for the coverage of an Eligible Dependent due to a
legally valid marriage or Registered Domestic Partner. To apply for coverage, the Covered Employee /Retiree must
complete the Enrollment Form through Monroe County Group Health Plan Administrator (Benefits Office). The
Covered Employee /Retiree must make application for enrollment within 30 days of the marriage or the registration
of the Domestic Partnership. The Effective Date of coverage for an Eligible Dependent who is enrolled as a result
of marriage is the date of the marriage; if enrolled as a result of a Registered Domestic Partnership is the date of the
registration.
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.
Enrollment and Effective Date of Coverage 10-5
Upon receipt of a MCSO or NMSN the Monroe County Group Health Plan Administrator (Benefits Office) will:
1. Notify the Covered Employee /Retiree and each Alternate Recipient, in writing, of the Plan's procedure
for determining if the order or notice is a QMCSO;
2. Make a determination of the qualified status of the order or notice within a reasonable time;
3. Notify the Covered Employee /Retiree and each Alternate Recipient, in writing, of the Plan's
determination; and
4. If the notice is a NMSN, notify the applicable government agency of its determination within a reasonable
period of time not (not to exceed 40 business days).
If the notice is an NMSN, the Monroe County Group Health Plan Administrator (Benefits Office) will also notify
the government agency that issued the notice:
1. Whether or not coverage is available to the Alternate Recipient;
2. Whether or not the Alternate Recipient is enrolled;
3. What coverage options are available to the Alternate Recipient;
4. The effective date of coverage; and
5. What steps the custodial parent (or agency) must take to obtain coverage.
Once the Monroe County Group Health Plan Administrator (Benefits Office) determines that the order or notice is
a QMCSO, the Monroe County Group Health Plan Administrator (Benefits Office) will determine the effective
date of coverage and enroll each Alternate Recipient as required by the order and make any necessary payroll
deductions from the Covered Employee. Covered Retirees would make monthly premium payments.
Other Provisions Regarding Enrollment and Effective Date of Coverage
Individuals who are rehired as employees of Monroe County Board of County Commissioners; Clerk of the Circuit
Court; Land Authority; Property Appraiser; Sheriffs Department; Supervisor of Elections and Tax Collector are
considered newly hired employees for purposes of this section. The provisions of the Monroe County Group
Health Plan Document 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 10-6
SECTION 'I 'I - TERMINATION OF COVERAGE
Termination of a Covered Employee's/ Retiree's Coverage
A Covered Plan Participant's coverage under the Monroe County Group Health Plan Document will automatically
terminate at 11:59:59 p.m.:
1. on the date the Monroe County Group Health Plan terminates;
2. on the day the Covered Employee terminates employment;
3. on the date the Covered Employee's coverage is terminated for cause (see the Termination of an Individual
Coverage for Cause subsection); or
4. The date ending the period for which contributions (if required) have been paid.
Termination of a Covered Dependent's Coverage
A Covered Dependent's coverage under the Monroe County Group Health Plan Document will automatically
terminate at 11:59:59 p.m.:
1. on the date the Monroe County Group Health Plan terminates:
2. on the date the Covered Dependent's coverage terminates for any reason;
a. as further clarification for purposes of this subsection, a Covered Dependent child who has reached
the end of the Calendar Year in which he or she becomes 25, but who has not reached the end of
the Calendar Year in which the Covered Dependent child becomes 30 will lose coverage if the
Covered Dependent child incurs any of the following:
t. marriage;
ii. no longer resides in Florida or is no longer a full -time or part -time student;
iii. obtains a dependent (e.g., through birth or adoption);
iv. obtains other coverage; or
v. on the date of termination of the Covered Employee's coverage.
3. on the last day of the first month that the Covered Dependent fails to continue to meet any of the
applicable eligibility requirements (e.g., a child reaches the limiting age, or a spouse is divorced from the
Covered Employee /Retiree);
4. on the date specified by the Monroe County Group Health Plan Administrator that the Covered
Dependent's coverage terminates; or
on the date the Monroe County Group Health Plan Administrator specifies that the Covered Dependent's
coverage is terminated for cause.
6. Pursuant to the provisions of H.R. 2851 ( "Michelle's Law "), an Eligible Dependent Child's non - attendance
at a secondary school, college or university due to a Medically Necessary leave of absence will not cause
termination of participation in the Plan until the date that is the earlier of-
Termination of Coverage 11 - 1
a. One (1) year after the first day of commencement of the leave of absence, provided:
(1) The Eligible Dependent Child was enrolled in the Plan on the basis of being a Full Time
Student immediately before the first day of the leave of absence and:
(2) The Monroe County Group Health Plan Administrator has received written certification by
an attending Physician which states the Eligible Dependent Child is suffering from a
serious illness or injury and the leave of absence is Medically Necessary; or
b. The date on which participation would otherwise terminate under the terms of the Monroe County
Group Health Plan Document.
Note: An Eligible Dependent Child whose participation under the Plan is continued under this section will be
entitled to the same benefits to which the Eligible Dependent Child was entitled prior to the Medically Necessary
leave of absence. If Monroe County Group Health Plan Document changes occur during the Eligible Dependent
Child's Medically Necessary leave of absence, the provisions of this section will apply to the changed coverage as if
it were the previous coverage.
In the event a Covered Employee wishes to delete a Covered Dependent from coverage, an Enrollment Form must
be forwarded to the Monroe County Group Health Plan Administrator (Benefits Office).
In the event a Covered Employee wishes to terminate a spouse's coverage, (e.g., in the case of divorce), or a
Registered Domestic Partner (e.g., dissolution of partnership), the Covered Employee must submit an Enrollment
Form to the Monroe County Group Health Plan Administrator (Benefits Office), prior to the requested termination
date or within 10 days of the date the divorce is final or 30 days after the dissolution of domestic partnership,
whichever is applicable.
Termination of a Covered Plan Participant's Coverage for Cause
In the event any of the following occurs, Monroe County Group Health Plan Administrator may terminate a
Covered Plan Participant's coverage for cause:
1. fraud, material misrepresentation or omission in applying for coverage or benefits; or
2. the knowing misrepresentation, omission or the giving of false information on Enrollment Forms or other
forms completed, by a Covered Plan Participant or on their behalf.
Cessation of Active Work
Approved Medical Leave — If an Eligible Employee ceases Active Work due to illness, injury or pregnancy their
Employer in its sole discretion may approve a medical leave of absence. Coverage for the Eligible Employee will
continue under the Plan, but for no longer than 6 (six) months from the date the approved medical leave begins.
Coverage of Eligible Dependents will continue during this time provided required premiums are continued to be
paid. Notification of all approved medical leave must be provided to the Monroe County Group Health
Administrator (Benefits Office) by the Employer. The notification should contain the date of when the leave began
and when it will end. An Eligible Employee who has been on an approved medical leave must return to active
work for a minimum of 30 days after the approved medical leave ends. In the event an Eligible Employee on an
approved medical leave does not return to active work at the end of the leave, the Eligible Employee will be
required to reimburse the Plan for the health benefit premiums paid during the leave to continue coverage.
Termination of Coverage 11-2
*Note: When an Eligible Employee fails to return to active work because of the continuation, recurrence, or onset
of either a serious health condition of the Eligible Employee or an Eligible Employee's family member the Plan will
not recover the health benefit premium payments made on the Eligible Employee's behalf during the approved
medical leave. The Monroe County Group Health Plan Administrator (Benefits Office) may require medical
certification of the Eligible Employee's or the Eligible Employees family member's serious health condition.
Rehire /Reinstatement — If subsequent to termination of coverage an Eligible Employee is rehired or reinstated as
an Eligible Employee the Eligible Employee must meet the eligibility requirements in the Eligibility for Coverage
section. However, the Plan allows a grace period of 2 days following the date of termination of coverage during
which an Eligible Employee may be rehired or reinstated without penalty.
Active Military Duty — Return from active military duty by a former Eligible Employee of two weeks or longer
who is rehired or reinstated will be treated as if the Eligible Employee were on an approved leave of absence for
purposes of eligibility under the Plan. The Plan's waiting period or preexisting condition exclusion period will not
be applicable.
Notice of Termination
It is the Monroe County Group Health Plan Administrator's responsibility to immediately notify a Covered Plan
Participant in the event his or her coverage is terminated for any reason.
Certification of Creditable Coverage
In the event coverage terminates for any reason, a written certification of Creditable Coverage will be issued to the
individual losing coverage.
The certification of Creditable Coverage will indicate the period of time the individual was enrolled under the Plan.
Creditable Coverage may reduce the length of any Pre - existing Condition exclusionary period by the length of time
the individual had prior Creditable Coverage.
Upon request, another certification of Creditable Coverage will be sent to the individual within a 24- month period
after termination of coverage.
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 11-3
SECTION 12 - CONTINUING COVERAGE UNDER COBRA
Federal continuation of coverage law is known as the Consolidated Omnibus Budget Reconciliation Act of 1987
(COBRA). Under COBRA Covered Plan Participants may be entitled to continue coverage for a limited period of
time, if they meet the applicable requirements, make a timely election, and pay the proper amount required to
maintain coverage.
A Covered Plan Participant must contact the Monroe County Group Health Plan Administrator (Benefits Office) to
determine their entitlement to COBRA continuation coverage. The Monroe County Group Health Plan
Administrator is solely responsible for meeting all of the employer's obligations under COBRA, including the
obligation to notify all Covered Plan Participants of their rights under COBRA. If a Covered Plan Participant fails
to meet the obligations under COBRA, the Monroe County Group Health Plan will not be liable for any claims
incurred by a Covered Plan Participant after termination of coverage.
A summary of COBRA rights and the general conditions for qualification for COBRA continuation coverage is
provided below.
Under COBRA:
A Covered Plan Participant may elect to continue coverage for a period not to exceed 18 months* in the
case of-
a) termination of employment of the Covered Employee other than for gross misconduct; or
b) reduced hours of employment of the Covered Employee.
*Note: A Covered Plan Participant is eligible for an 11 month extension of the 18 month COBRA
continuation coverage option above (to a total of 29 months) if the Covered Plan Participant is totally disabled as
defined by the Social Security Administration (SSA) at the time of termination, reduction in hours or within the first
60 days of COBRA continuation coverage. The Covered Plan Participant must supply notice of the disability
determination to the Monroe County Group Health Plan Administrator (Benefits Office) within 18 months of
becoming eligible for continuation coverage and no later than 60 days after the SSA's determination date.
2. A Covered Eligible Dependent(s) may elect to continue their coverage for a period not to exceed 36 months
in the case of:
a) the Covered Employee's entitlement to Medicare;
b) divorce of the Covered Employee;
c) dissolution of Domestic Partnership of the Covered Employee /Retiree;
c) death of a Covered Employee or Covered Retiree*
d) the employer filed bankruptcy (subject to bankruptcy court approval); or
e) a dependent child may elect the 36 month extension if the dependent child ceases to be an
Eligible Dependent under the terms of the Monroe County Group Health Plan coverage.
*Note: Upon the death of a Covered Retiree the Surviving Spouse may continue coverage under the Monroe
County Group Health Plan provided: 1) they do not remarry; and 2) they make timely payment of any required
contribution. It is the sole responsibility of the Surviving Spouse to notify the Monroe County Group Health Plan
Administrator (Benefits Office) of a change in their marital status.
Children born to or placed for adoption with the Covered Employee during the continuation coverage periods
noted above are also eligible for the remainder of the continuation period.
Continuing Coverage Under COBRA 12-1
Additional requirements applicable to continuation of coverage under COBRA are set forth below:
Monroe County Group Health Plan Administrator (Benefits Office) must notify all Covered Plan
Participants of the continuation of coverage rights under COBRA within 14 days of the event which creates
the continuation option. If coverage would be lost due to Medicare entitlement, divorce, or the failure of a
Covered Dependent child to meet eligibility requirements, the Covered Plan Participant must notify the
Monroe County Group Health Administrator (Benefits Office), in writing, within 60 days of any of these
events. Monroe County Group Health Plan Administrator's 14 -day notice requirements runs from the date
of the receipt of such notice.
2. A Covered Plan Participant must elect to continue the coverage within 60 days of the later of-
a) the date that the coverage terminates: or
b) the date the notification of continuation of coverage rights is sent by the Monroe County Group
Health Plan Administrator.
3. COBRA coverage will terminate if the Covered Plan Participant becomes 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 the Covered Plan
Participant's coverage.
4. COBRA coverage will terminate if the Covered Plan Participant becomes entitled to Medicare.
5. If a Covered Plan Participant is totally disabled and elects to extend the continuation of coverage, such
extension of coverage may not continue for more than 30 days after determination by the Social Security-
Administration that the Covered Plan Participant is no longer disabled. The Covered Plan Participant must
inform Monroe County Group Health Plan Administrator (Benefits Office) of the Social Security
Administration's determination within 30 days of such determination.
6. A Covered Plan Participant must meet all contribution requirements, and all other eligibility requirements
described in COBRA, and to the extent not inconsistent with COBRA, in the Monroe County Group
Health Plan Document.
7. COBRA coverage will terminate on the date the Monroe County Group Health Plan ceases to provide
group health coverage to its employees.
An election by a Covered Employee or Covered Dependent spouse shall be deemed to be an election for any other
qualified beneficiary related to that Covered Employee or Covered Dependent spouse, unless otherwise specified in
the election form.
Note: This section shall not be interpreted to grant any continuation rights in excess of those required by
COBRA and /or Section 4980B of the Internal Revenue Code. Additionally, the Monroe County Group
Health Plan Document shall be deemed to have been modified, and shall be interpreted, so as to comply
with COBRA and changes to COBRA that are mandatory with respect to the Monroe County Group
Health Plan Document.
Continuing Coverage Under COBRA 12-2
SECTION 13 - CONVERSION PRIVILEGE
Eligibility Criteria for Conversion
Covered Plan Participants are entitled to apply for an individual insurance conversion policy (hereinafter referred to
as a "converted policy" or "conversion policy ") if:
1. they were continuously covered for at least three months under the Monroe County Group Health Plan D,
and /or under another group policy that provided similar benefits immediately prior to the Monroe Count-
Group Health Plan; and
2. their coverage was terminated for any reason, including discontinuance of the Plan in its entirety and
termination of continued coverage under COBRA.
The Covered Plan Participant must notify the Plan Administrator (Benefits Office) in writing or by telephone if he
or she is interested in a conversion policy. Within 14 days of such notice, a conversion policy brochure and outline
of coverage will be mailed to the Covered Plan Participant. The brochure contains easy steps to follow to obtain a
Conversion Application.
Note: The conversion policy must be applied within 31 days after the date health coverage ends. In the event an
application is not received within 31 days, the converted policy application will be denied and the individual will not
be entitled to a converted policy.
Additionally, a Covered Plan Participant who loses coverage is not entitled to a converted policy if-
1. he or she is eligible for or covered under the Medicare program;
2. he or she failed to pay, on a timely basis, the contribution required for coverage under the Plan;
3. The Plan was replaced within 31 days after termination by any group policy, contract, plan, or program,
including a self - insured plan or program, which provides benefits similar to the benefits provided under the
Monroe County Group Health Plan Document.
Neither the Plan nor Wells Fargo TPA has any obligation to notify individuals losing coverage of this
conversion privilege when coverage terminates nor at any other time. It is each Covered Plan Participant's
sole responsibility to exercise this conversion privilege by notifying the Plan Administrator (Benefits
Office) in writing or by telephone if he or she is interested in a conversion policy within 31 days of the
termination of their coverage under the Monroe County Group Health Plan Document. The converted
policy may be issued without evidence of insurability and shall be effective the day following the day
coverage under the Monroe County Group Health Plan terminated.
Note: The conversion policies are not a continuation of coverage under COBRA or any other states' similar laws.
Conversion Privilege 13-1
SECTION 14 - EXTENSION OF BENEFITS
Extension of Benefits
In the event the Plan is terminated, coverage will not be provided under the Monroe County Group Health Plan
Document for any Service rendered on or after the termination date. The extension of benefits provisions
described below only apply when the entire Group Health Plan is terminated. The extension of benefits described
in this section does not apply when an individual's coverage terminates if the Plan remains in effect. The extension
of benefits provisions are subject to all of the other provisions, including the limitations and exclusions.
Note: It is each individual's sole responsibility to provide acceptable documentation showing that he or she is
entided to an extension of benefits.
In the event an individual is totally disabled on the termination date of the Plan as a result of a specific
Accident or illness incurred while the Covered Plan Participant was covered under the Plan, as determined
by the Plan Administrator, a limited extension of benefits will be provided under the Plan for the disabled
individual only. This extension of benefits is for Covered Services necessary to treat the disabling Condition
only. This extension of benefits will only continue as long as the disability is continuous and uninterrupted.
In any event, this extension of benefits will automatically terminate at the end of the 12 -month period
beginning on the termination date of the Plan.
For purposes of this section, an individual will be considered "totally disabled" only if, in Wells Fargo TPA or
Monroe County Group Health Plan Administrator's opinion, he or she is unable to work at any gainful job for
which he or she is suited by education, training, or experience, and he or she requires regular care and attendance by
a Physician. A Covered Plan Participant is considered totally disabled only if, in Wells Fargo TPA or Monroe
County Group Health Plan Administrator's opinion, he or she is unable to perform those normal day -to -day
activities which he or she would otherwise perform and he or she requires regular care and attendance by a
Physician.
2. In the event an individual is receiving covered dental treatment as of the termination date of the Plan a
limited extension of such covered dental treatment will be provided under the Monroe County Group
Health Plan Document if-
a) a course of dental treatment or dental procedures were recommended in writing and commenced in
accordance with the terms specified herein while the individual was covered under the Plan;
b) dental procedures other than routine examinations, prophylaxis, x -rays, sealants, or orthodontic
services; and
c) the dental procedures were performed within 90 days after the Plan terminated.
This extension of benefits is for Covered Services necessary to complete the dental treatment only. This extension
of benefits will automatically terminate at the end of the 90 -day period beginning on the termination date of the
Monroe County Group Health Plan or on the date the individual become covered under a succeeding insurance,
health maintenance organization or self - insured plan providing coverage or Services for similar dental procedures.
The individual is not required to be totally disabled in order to be eligible for this extension of benefits.
Please refer to the Dental Care subsection of the "Covered Services" section for a description of the dental care
Services covered under the Monroe County Group Health Plan Document.
Extension of Benefits 14-1
3. In the event an individual is pregnant as of the termination date of the Plan, a limited extension of the
maternity expense benefits included in the Monroe County Group Health Plan Document will be available,
provided the pregnancy commenced while the pregnant individual was covered under the Plan as
determined by Wells Fargo TPA or the Monroe County Group Health Plan Administrator. 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. The individual is not required to be totally
disabled in order to be eligible for this extension of benefits.
Extension of Benefits 14-2
SECTION 15 - MEDICARE COVERAGEIMEDICARE SECONDARY
PAYER PROVISIONS
Active Employees
When an active Covered Plan Participant becomes covered under Medicare and continues to be eligible and
covered under the Monroe County Group Health Plan Document, coverage under the Monroe County Group
Health Plan Document will be primary and the Medicare benefits will be secondary, but only to the extent required
by law. In all other instances, coverage under the Monroe County Group Health Plan Document will be secondary
to any Medicare benefits. To the extent the benefits under the Monroe County Group Health Plan Document are
primary, claims for Covered Services should be filed with Wells Fargo TPA first. If an Eligible Employee or any of
their eligible dependents who are covered under the Plan and Medicare, benefits from the Plan will coordinate with
any other benefits received and total benefits payable will not exceed 100% of the Allowed Amount.
It is important for the Covered Plan Participant to enroll in Medicare as soon as the Covered Plan Participant
becomes eligible.
Retired Employees
Retirees, their eligible spouses, or a surviving spouse enrolled in Medicare, Medicare will be pay benefits for the
covered individual first and the Plan will pay benefits second. The total benefits paid will never be more than 100%
of the Allowed Amount. Once eligible, retirees and their spouses should enroll in Medicare Parts A and B.
The Plan will pay as the secondary on all claims received from Medicare eligible Covered Plan
Participants who are retired.
Covered Plan Participants covered under COBRA who become eligible for Medicare will no longer be eligible to
continue coverage.
Individuals With End Stage Renal Disease
If a Covered Plan Participant turns 65 or becomes eligible for Medicare due to End Stage Renal Disease ( "ESRD "),
the Covered Plan Participant must immediatel,Ty the Monroe Coun Group Health Plan Administrator
Benefits Office
If a Covered Plan Participant becomes entitled to Medicare coverage because of ESRD, coverage under the Monroe
County Group Health Plan Document will be provided on a primary basis for 30 months beginning with the earlier
o£
1. the month in which the Covered Plan Participant became entitled to Medicare Part "A" ESRD benefits; or
2. the first month in which the Covered Plan Participant would have been entitled to Medicare Part "A"
ESRD benefits if a timely application has been made.
If Medicare was primary prior to the time a Covered Plan Participant became eligible due to ESRD, then Medicare
will remain primary (i.e., retirees and /or their spouses or registered domestic partners over the age of 65). Also, if
coverage under the Monroe County Group Health Plan Document was primary prior to ESRD entitlement, then
coverage hereunder will remain primary for the ESRD coordination period. If a Covered Plan Participant becomes
eligible for Medicare due to ESRD, coverage will be provided, as described in this section, on a primary basis for 30
months.
Medicare Coverage /Medicare Secondary Payer Provisions 15-1
Disabled Active Individuals
If an active Covered Plan Participant is entitled to Medicare coverage because of a disability other than ESRD,
Medicare benefits will be secondary to the benefits provided under the Monroe County Group Health Plan
Document provided that Monroe County Board of County Commissioners employed at least 100 or more full -time
or part -time employees.
Miscellaneous
1. This section shall be subject to, modified (if necessary) to conform to or comply with, and interpreted with
reference to the requirements of federal statutory and regulatory Medicare Secondary Payer provisions as
those provisions related to Medicare beneficiaries who are covered under the Monroe County Group Health
Plan Document.
2. Wells Fargo TPA will not be liable to the Plan or to any individual covered under the Monroe County
Group Health Plan Document on account of any nonpayment of primary benefits resulting from any failure
of performance on Monroe County Group Health Plan Administrator's obligations as described in this
section.
Medicare Coverage /Medicare Secondary Payer Provisions 15-2
SECTION 16 - COORDINATION OF BENEFITS
Coordination of Benefits ( "COB ") is a limitation of coverage and /or benefits to be provided under the Monroe
County Group Health Plan Document.
COB determines the manner in which expenses will be paid when a Covered Plan Participant is covered under
more than one health plan, program, or policy providing benefits for Health Care Services. COB is designed to
avoid the costly duplication of payment for Covered Services. It is the Covered Plan Participants responsibility to
provide to Wells Fargo TPA and the Monroe County Group Health Plan Administrator information concerning
any duplication of coverage under any other health plan, program, or a Covered Plan Participant may have. This
means the Covered Plan Participant must notify Wells Fargo TPA and the Monroe County Group Health Plan
Administrator (Benefits Office) in writing if there is other applicable coverage or if there is not. Covered Plan
Participants may be requested to provide this information at initial enrollment, by written correspondence annually
thereafter, or in connection with a specific Health Care Services received. If the information is not received, claims
may be denied and the Covered Plan Participant will be responsible for payment of any expenses related to denied
claims.
Health plans, programs or policies which may be subject to COB include, but are not limited to, the following
which will be referred to as "plan(s)" for purposes of this section:
1. any group or non -group health insurance, group -type self - insurance, or HMO plan;
2. any other plan, program or insurance policy, including an automobile PIP insurance policy and /or medical
payment coverage with which the law permits coordination of benefits;
3. Medicare, as described in "Medicare Coverage /Medicare Secondary Payer Provisions" section; and
4. to the extent permitted by law, any other government sponsored health insurance program.
The amount of payment, if any, when benefits are coordinated under this section, is based on whether or not the
benefits under the Monroe County Group Health Plan Document are primary. When primary, payment will be
made for Covered Services without regard to coverage under other plans. When the benefits under the Monroe
County Group Health Plan Document are not primary, payment for Covered Services may be reduced so that total
benefits under all plans will not exceed 100 percent of the total reasonable expenses actually incurred for Covered
Services. In the event that the primary payer's payment exceeds the Allowed Amount, no payment will be
made for such Services under the Monroe County Group Health Plan Document.
The following rules shall be used to establish the order in which benefits under the respective plans will be
determined:
When an individual is covered as a Covered Dependent and the other plan covers the individual as other
than a dependent, the Plan will be secondary.
2. When the Plan covers a dependent child whose parents are not divorced:
a) the plan of the parent whose birthday, excluding year of birth, falls earlier in the year will be primary;
or
b) if both parents have the same birthday, excluding year of birth, and the other plan has covered one of
the parents longer than the Plan, the Plan will be secondary.
3. When the Plan covers a dependent who parents are divorced:
Coordination of Benefits 16-1
a) if the parent with custody is not remarried, the plan of the parent with custody is primary;
b) if the parent with custody has remarried, the plan of the parent with custody is primary; the
stepparent's plan is secondary; and the plan of the parent without custody pays last;
c) regardless of which parent has custody, whenever a court decree specifies the parent who is
financially responsible for the child's health care expenses, the plan of that parent is primary.
4. When the Plan covers a dependent child and the dependent child is also covered under another plan:
a) the plan of the parent who is neither laid off nor retired will be primary; or
b) if the other plan is not subject to this rule, and if, as a result, such plan does not agree on the order
of benefits, this paragraph shall not apply
5. When rules 1, 2, 3, and 4 above do not establish an order of benefits, the plan which has covered the
Covered Plan Participant the longest shall be primary.
6. If the Covered Plan Participant is covered under a COBRA continuation plan as a result of the purchase of
coverage as provided under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, and
also under another group plan, the following order of benefits applies:
a) first, the plan covering the person as an employee, or as the employee's Dependent; and
b) second, the coverage purchased under the plan covering the person as a former employee, or as the
former employee's Dependent provided according to the provisions of COBRA.
7. If the other plan does not have rules that establish the same order of benefits as under the Monroe County
Group Health Plan Document, the benefits under the other plan will be determined primary to the benefits
under the Monroe County Group Health Plan Document.
Coordination of benefits shall not be permitted against an indemnity -type policy, an excess insurance policy as
defined in Florida Statutes Section 627.635, a policy with coverage limited to specified illnesses or accidents, or a
Medicare supplement policy.
Coordination of Benefits Exclusion
Prescription Drug Program Copayments, Coinsurance and Deductible, or any part thereof, the Covered Plan
Participant's are obligated to pay under any plan or policy.
Non - Duplication of Government Programs and Workers' Compensation
The benefits under the Monroe County Group Health Plan Document shall not duplicate any benefits Covered
Plan Participant are entitled to or eligible for under government programs (e.g., Medicare, Medicaid, Veterans
Administration) or Workers' 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.
Coordination of Benefits 16-2
SECTION 17 - SUBROGATION, RIGHT OF REIMBURSEMENT AND
EQUITABLE LIEN
Subrogation
The Plan Administrator has rights of subrogation, which helps the Plan Administrator to continue providing cost -
effective healthcare benefits.
In the event payment is made under the Monroe County Group Health Plan Document to or on behalf of a
Covered Plan Participant for any claim in connection with or arising from a Condition resulting, directly or
indirectly, from an intentional act or from the negligence or fault of any third person or entity, the Plan
Administrator to the extent of any such payment, shall be subrogated, i.e., shall succeed, to all causes of action and
all rights of recovery that the Covered Plan Participant may have against any person or entity. Such subrogation
rights shall extend and apply to any settlement of a claim, regardless of whether litigation has been initiated. Wells
Fargo TPA may recover, on behalf of the Plan Administrator, the amount of any payments made on behalf of a
Covered Plan Participant minus a pro rata share for any costs and attorney fees incurred by a Covered Plan
Participant in pursuing and recovering damages. Wells Fargo TPA may subrogate, on behalf of the Plan
Administrator, against all money recovered regardless of the source of the money including, but not limited to,
uninsured motorists coverage. Although the Plan Administrator may, but is not required, to take into consideration
any special factors relating to the Covered Plan Participant's specific case in resolving the subrogation claim, the
Plan Administrator will have the first right of recovery out of any recovery or settlement the Covered Plan
Participant is able to obtain even if the Covered Plan Participant or Covered Plan Participant's or their attorney
believes that the Covered Plan Participant has not been made whole for his /her losses or damages by the amount of
the recovery or settlement.
The Covered Plan Participant is required to:
• Provide information pertaining to litigation and settlement, including settlement negotiations;
• Provide any assistance necessary to allow the Plan Administrator and /or Wells Fargo TPA to enforce its
right to subrogation or reimbursement;
• Notify the Plan Administrator and /or Wells Fargo TPA before entering into any settlement negotiations
with any third party and prior to executing any settlement agreement with the third party; and
• Obtain the consent of Wells Fargo TPA prior to entering into any settlement agreement with the third
party.
No settlement agreement, waiver, or release of liability that you execute without notice to Wells Fargo TPA will be
valid or binding on Wells Fargo TPA or the Plan Administrator.
Right of Reimbursement
If any payment under the Monroe County Group Health Plan Document is made to or on behalf of a Covered Plan
Participant with respect to an injury or illness resulting from the intentional act, negligence, or fault of a third
person or entity, BOCC and /or the Plan will have a right to be reimbursed by the Covered Plan Participant (out of
any settlement or judgment proceeds recovered by the Covered Plan Participant) one dollar ($1.00) for each dollar
paid under the terms of the Monroe County Group Health Plan Document minus a pro rata share of any costs and
attorney fees incurred in pursuing and recovering such proceeds.
The BOCC and /or the Plan's right of reimbursement will be in addition to any subrogation right or claim available
to the BOCC, and the Covered Plan Participant must execute and deliver such instruments or papers pertaining to
Subrogation, Right of Reimbursement and Equitable Lien 17-1
any settlement or claim, settlement negotiations, or litigation as may be requested by Wells Fargo TPA on behalf of
the BOCC and /or the Plan, to exercise the BOCC and /or the Plan's right of reimbursement hereunder. Covered
Plan Participant's or their lawyer must notify Wells Fargo TPA, by certified or registered mail, if a Covered Plan
Participant intends to claim damages from someone for injuries or illness. A Covered Plan Participant must do
nothing to prejudice the BOCC and /or the Plan's right of reimbursement hereunder and no waiver, release of
liability, or other documents executed by the Covered Plan Participant, without notice to and consent of Wells
Fargo TPA acting on behalf of the BOCC, will be binding upon the BOCC.
Equitable Lien
The Plan shall have an equitable lien against any rights the Covered Plan Participant may have to recover any
payments made by the Plan from any other party, including an insurer or another group health plan. Recovery shall
be limited to the amount of reimbursable payments made by the Plan. The equitable lien also attaches to any right
to payment for workers' compensation, whether by judgment or settlement, where the Plan has paid expenses
otherwise eligible as Covered Medical Services prior to a determination that the Covered Medical Services arose out
of and in the course of employment. Payment by workers compensation insurers or the employer will be deemed
to mean that such a determination has been made.
This equitable lien shall also attach to the first right of recovery to any money or property that is obtained by
anybody (including, but not limited to, the Covered Plan Participant, the Covered Plan Participant's attorney,
and /or trust) as a result of an exercise of the Covered Plan Participant's right of recovery. The Plan shall also be
entided to seek any other equitable remedy against any party possessing or controlling such monies or properties.
At the discretion of the Monroe County Group Health Plan Administrator, the Plan may reduce any future Covered
Medical Services otherwise available to the Covered Plan Participant under the Plan by an amount up to the total
amount of reimbursable payments made by the Plan that is subject to the equitable lien.
General Provisions — The following provisions shall apply to the Plan's right of subrogation, reimbursement and
creation of an equitable lien. The subrogation, reimbursement, and equitable lien rights apply to any benefits paid
by the Plan on behalf of the Covered Plan Participant as a result of the injuries sustained, including but not limited
to:
1. any no -fault insurance;
2. medical benefits coverage under any automobile liability plan. This includes the Covered Plan Participant's
plan or any third party's policy under which the Covered Plan Participant is entided to benefits;
3. under - insured or uninsured motorist coverage;
4. any automobile Medical Payments and Personal Injury Protection benefits; and
5. any third party's liability insurance
In addition:
The Plan may make total payments that exceed the maximum amount to which the Covered Plan
Participant is entided at any time under the Plan. In the event of such payments the Plan shall have the
right to recover the excess amount from any persons to, or for, or with respect to whom such excess
payments were made.
2. The Plan provides that recovery of excess amounts may include a reduction from future benefit payments
available to the Covered Plan Participant under the Plan of an amount up to the aggregate amount of
reimbursable payments that have not been reimbursed to the Plan.
Subrogation, Right of Reimbursement and Equitable Lien 17-2
3. The provisions of the Monroe County Group Health Plan Document concerning subrogation,
reimbursement, equitable liens and other equitable remedies are also intended to supersede the applicability
of the federal common law doctrines commonly referred to as the "make whole" rule and the "common
fund" rule.
4. The reimbursement required under this provision will not be reduced to reflect any costs or attorneys' fees
incurred in obtaining compensation unless separately agreed to, in writing, by the Monroe County Group
Health Plan Administrator in the exercise of its sole discretion.
The Covered Plan Participant agrees to sign any documents requested by the Plan including but not limited
to reimbursement and /or subrogation agreements as the Monroe County Group Health Plan Administrator
or its agent(s) may request. Also, the Covered Plan Participant agrees to furnish any other information as
may be requested by the Monroe County Group Health Plan Administrator or its agent(s). Failure or
refusal to execute such agreements or furnish information does not preclude the Monroe County Group
Health Plan Administrator from exercising its right to subrogation or obtaining full reimbursement. Any
settlement or recovery received shall first be deemed for reimbursement of medical expenses paid by the
Monroe County Group Health Plan Document. Any excess after 100 percent reimbursement of the Plan
may be divided up between the Covered Plan Participants and their attorney if applicable. The Covered
Plan Participant agrees to take no action which in any way prejudices the right of the Monroe County
Health Plan Document.
6. The Monroe County Group Health Plan Administrator has sole discretion to interpret the terms of this
provision in its entirety and reserves the right to make changes as it deems necessary.
7. If the Covered Plan Participant takes no action to recover money from any source, then the Covered Plan
Participant agrees to allow the Plan to initiate its own direct action for reimbursement.
Subrogation, Right of Reimbursement and Equitable Lien 17-3
SECTION 18 - CLAIMS PROCESSING
Introduction
This section is intended to:
• Help the Covered Plan Participant understand what the Covered Plan Participant or the Covered Plan
Participant's treating Providers must do, under the terms of the Monroe County Group Health Plan
Document, in order to obtain payment for expenses for Covered Services they have rendered or will render
to the Covered Plan Participant; and
• Provide the Covered Plan Participant with a general description of the applicable procedures that will be
used for making Adverse Benefit Determinations, Concurrent Care Decisions and for notifying the Covered
Plan Participant when benefits are denied.
Under no circumstances will Wells Fargo TPA be held responsible for, nor will Wells Fargo TPA accept liability
relating to, the failure of the Monroe County Group Health Plan Administrator to: 1) comply with any applicable
disclosure requirements; 2) provide the Covered Plan Participant with a Monroe County Group Health Plan
Document; or 3) comply with any other legal requirements. The Covered Plan Participant should contact Wells
Fargo TPA or the Monroe County Group Health Plan Administrator (Benefits Office) with questions relating to the
Monroe County Group Health Plan Document. The Plan Administrator is the BOCC (Benefits Office).
Types of Claims
For purposes of the Monroe County Group Health Plan Document there are three types of claims: 1) Pre - Service
Claims; 2) Post - Service Claims; and 3) Claims Involving Urgent Care. It is important that the Covered Plan
Participant become familiar with the types of claims that can be submitted to Wells Fargo TPA and the timeframes
and other requirements that apply. This section defines and describes the three types of claims that may be
submitted to Wells Fargo TPA.
Post - Service Claims
How to File a Post - Service Claim
Experience shows that the most common type of claim Wells Fargo TPA will receive from the Covered Plan
Participant or the Covered Plan Participant's treating Providers will likely be Post - Service Claims.
Most PPO Providers will file Post - Service Claims for services rendered to a Covered Plan Participant. In the event
a Provider who renders services to a Covered Plan Participant does not file a Post - Service Claim for such services, it
is the Covered Plan Participant's responsibility to file it with Wells Fargo TPA.
Wells Fargo TPA must receive a Post - Service Claim within 90 days of the date the Health Care Service was
rendered or, if it was not reasonably possible to file within such 90 -day period, as soon as possible. In any event, no
Post - Service Claim will be considered for payment if Wells Fargo TPA does not receive it at the address indicated
on the Covered Plan Participant's ID Card within one year of the date the service was rendered unless the Covered
Plan Participant was legally incapacitated.
Claims Processing 18-1
For a Post - Service Claim, Wells Fargo TPA must receive an itemized statement from the health care Provider for
the service rendered along with a completed claim form. The itemized statement must contain the following
information:
1. the date the service was provided;
2. a description of the service including any applicable procedure code(s);
3. the amount actually charged by the Provider;
4. the diagnosis including any applicable diagnosis code(s);
5. the Provider's name and address;
6. the name of the individual who received the service; and
7. the Covered Employee's name and group number as they appear on the ID Card.
The itemized statement and claim for must be received by Wells Fargo TPA at the address indicated on the
Covered Plan Participant's ID Card.
Note: Please refer to the Prescription Drug Program under the Schedule of Benefits Section for information on
processing of prescription drug claims.
The Processing of Post - Service Claims
Wells Fargo TPA will use its best efforts to pay, contest, or deny all Post - Service Claims for which Wells Fargo TPA
has all of the necessary information, as determined by Wells Fargo TPA. Post - Service Claims will be paid,
contested, or denied within the timeframes described below.
• Payment for Post - Service Claims — When payment is due under the terms of the Monroe County Group
Health Plan Document, Wells Fargo TPA will use its best efforts to pay (in whole or in part) for
electronically submitted Post - Service Claims within 20 days of receipt. Likewise, Wells Fargo TPA will use
its best efforts to pay (in whole or in part) for paper Post - Service Claims within 30 days of receipt. If Wells
Fargo TPA is unable to determine whether the claim or a portion of the claim if payable because more or
additional information is needed, Wells Fargo TPA may contest the claim within the timeframes set forth
below.
• Contested Post - Service Claims — In the event Wells Fargo TPA contests an electronically submitted Post -
Service Claim, or a portion of such a claim, Wells Fargo TPA will use its best efforts to provide notice,
within 20 days of receipt, that the claim or a portion of the claim is contested. In the event Wells Fargo
TPA contests a Post - Service Claim submitted on a paper claim form, or a portion of such a claim, Wells
Fargo TPA will use its best efforts to provide notice, within 30 days of receipt, that the claim or a portion of
the claim is contested. The notice may identify: 1) the contested portion or portions of the claim; 2) the
reason(s) for contesting the claim or a portion of the claim; and 3) the date that Wells Fargo TPA reasonably
expects to notify the Covered Plan Participant of the decision. The notice may also indicate whether more
or additional information is needed in order to complete processing of the claim. If Wells Fargo TPA
requests additional information, Wells Fargo TPA must receive it within 45 days of the request for the
information. If Wells Fargo TPA does not receive the requested information, the claim or a portion
of the claim will be adjudicated based on the information in the possession of Wells Fargo TPA at
the time and may be denied. Upon receipt of the requested information, Wells Fargo TPA will use its
Claims Processing 18-2
best efforts to complete the processing of the Post - Service Claim within 15 days of receipt of the
information.
• Denial of Post - Service Claims — In the event Wells Fargo TPA denies a Post - Service Claim submitted
electronically, Wells Fargo TPA will use its best efforts to provide notice, within 20 days of receipt, that the
claim or a portion of the claim is denied. In the event Wells Fargo TPA denies a paper Post - Service Claim,
Wells Fargo TPA will use its best efforts to provide notice, within 30 days of receipt, that the claim or a
portion of the claim is denied. The notice may identify the denied portion(s) of the claim and the reason(s)
for denial. It is the Covered Plan Participant's responsibility to ensure that Wells Fargo Third Part-
Administrator receives all information determined by Wells Fargo TPA as necessary to adjudicate a Post -
Service Claim. If Wells Fargo TPA does not receive the necessary information, the claim or a portion
of the claim may be denied.
A Post - Service Claim denial is an Adverse Benefit Determination and is subject to the Adverse Benefit
Determination standards and appeals procedures described in this section.
Additional Processing Information for Post - Service Claims
In any event, Wells Fargo TPA will use its best efforts to pay or deny all: 1) electronic Post - Service Claims within
90 days of receipt of the completed claim; and 2) Post - Service paper claims within 120 days of receipt of the
completed claim. Claims processing shall be deemed to have been completed as of the date the notice of the claims
decision is deposited in the mail by Wells Fargo TPA or otherwise electronically transmitted. Any claims payment
relating to a Post - Service Claim that is not made by Wells Fargo TPA within the applicable timeframe is subject to
the loss of negotiated provider discounts through the PPO Networks.
Wells Fargo TPA will investigate any allegation of improper billing by a Provider upon receipt of written
notification from the Covered Plan Participant. If Wells Fargo TPA determines that the Covered Plan Participant
was billed for a service that was not actually performed, any payment amount will be adjusted and, if applicable, a
refund will be requested.
Pre - Service Claims
How to File A Pre - Service Claim
The Monroe County Group Health Plan Document may condition coverage, benefits, or payment (in whole or in
part), for a specific Covered Service, on the receipt by Wells Fargo TPA of a Pre - Service Claim as that term is
defined herein. In order to determine whether Wells Fargo TPA must receive a Pre - Service Claim for a particular
Covered Service, please refer to the Covered Services section and other applicable sections of the Monroe County
Group Health Plan Document. The Covered Plan Participant may also call the Wells Fargo TPA customer service
number on the Covered Plan Participant's ID card for assistance.
Wells Fargo TPA is not required to render an opinion or make a coverage or benefit determination with respect to a
service that has not actually been provided to the Covered Plan Participant unless the terms of the Monroe County
Group Health Plan Document require (or condition payment upon) approval by Wells Fargo TPA for the service
before it is received.
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 72 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
Claims Processing 18-3
determination, Wells Fargo TPA will provide notice within 24 hours o£ 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 o£ 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.
Benefit Determinations on Pre - Service Claims That Do Not Involve Urgent Care
Wells Fargo TPA will provide notice of a decision on a Pre - Service Claim not involving urgent care within 15 days
of receipt provided additional information is not required for a coverage decision. Wells Fargo TPA may extend
this 15 -day determination period one time for up to an additional 15 days. If such an extension is necessary, Wells
Fargo TPA will provide notice of the extension and reasons for it. Wells Fargo TPA will use its best efforts to
provide notification of the decision on the Covered Plan Participant's Pre - Service claim within a total of 30 days of
the initial receipt of the claim, if an extension of time was taken by Wells Fargo TPA.
If additional information is necessary to make a determination, Wells Fargo TPA will: 1) provide notice of the need
for additional information, prior to the expiration of the initial 15 -day period; 2) identify the specific information
that the Covered Plan Participant or the Covered Plan Participant's Provider may need to provide; and 3) inform
the Covered Plan Participant of the date that Wells Fargo TPA reasonably expects to notify the Covered Plan
Participant on the decision. If Wells Fargo TPA requests additional information, Wells Fargo TPA must receive it
within 45 days of the request for the information. Wells Fargo TPA will provide notification of the decision on the
Covered Plan Participant's Pre - Service Claim within 15 days of receipt of the requested additional information.
A Pre - Service Claim denial is an Adverse Benefit Determination and is subject to the Adverse Benefit
Determination standards and appeal procedures described in this section.
Concurrent Care Decisions
Reduction or Termination of Coverage or Benefits of Services
A reduction or termination of coverage or benefits for services will be considered an Adverse Benefit
Determination when:
• Wells Fargo TPA and or the Monroe County Group Health Plan Administrator has approved in writing
coverage or benefits for an ongoing course of services to be provided over a period of time or a number of
services to be rendered;
and
• the reduction or termination occurs before the end of such previously approved time or number of services;
and
• the reduction or termination of coverage or benefits by Wells Fargo TPA and /or the Monroe County
Group Health Plan Administrator was not due to an amendment of the Monroe County Group Health Plan
Document or termination of the Covered Plan Participant's coverage as provided by the Monroe County
Group Health Plan Document.
Wells Fargo TPA will notify the Covered Plan Participant of such reduction or termination in advance so that the
Covered Plan Participant will have a reasonable amount of time to have the reduction or termination reviewed in
accordance with the Adverse Benefit Determination standards and procedures described below. In no event shall
Claims Processing 18-4
Wells Fargo TPA be required to provide more than a reasonable period of time within which the Covered Plan
Participant may develop the appeal before Wells Fargo TPA actually terminates or reduces coverage for the
services.
Requests for Extension of Services
The Covered Plan Participant's Provider may request an extension of coverage or benefits for a service beyond the
approved period of time or number of approved services. If the request for an extension is for a Claim Involving
Urgent Care, Wells Fargo TPA will notify the Covered Plan Participant of the approval or denial of such requested
extension within 24 hours after receipt of the request, provided the request is received at least 24 hours prior to the
expiration of the previously approved number or length of coverage for such services. Wells Fargo TPA will then
notify the Covered Plan Participant within 24 hours i£ 1) additional information is needed; or 2) the Covered Plan
Participant or the Covered Plan Participant's representative failed to follow proper procedures in the request for an
extension. If Wells Fargo TPA and /or Monroe County Group Health Plan Administrator request additional
information, the Covered Plan Participant will have 48 hours to provide the requested information. Wells Fargo
TPA may notify the Covered Plan Participant orally or in writing, unless the Covered Plan Participant or the
Covered Plan Participant's representative specifically request that it be in writing. A denial of a request for
extension of services is considered an Adverse Benefit Determination and is subject to the Adverse Benefit
Determination review procedure below.
Standards for Adverse Benefit Determinations
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):
• the specific reason or reasons for the Adverse Benefit Determination;
• 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; and
• a description of the Covered Plan Participant's appeal rights with respect to the decision.
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.
Claims Processing 18-5
How to Appeal an Adverse Benefit Determination
The Covered Plan Participant, or a representative designated by the Covered Plan Participant in writing, has the
right to appeal an Adverse Benefit Determination. Wells Fargo TPA will review the Covered Plan Participant's
appeal through the review process described below. The Covered Plan Participant's appeal must be submitted in
writing to Wells Fargo TPA within 365 days of the original Adverse Benefit Determination, except in the case of
Concurrent Care Decisions which may, depending upon the circumstances, require the Covered Plan Participant to
file within a shorter period of time from notice of the denial. The following guidelines are applicable to reviews of
Adverse Benefit Determinations:
• Wells Fargo TPA must receive the Covered Plan Participant's appeal of an Adverse Benefit Determination
in person or in writing;
• The Covered Plan Participant may request to review pertinent documents, such as any internal rule,
guideline, protocol, or similar criterion relied upon to make the determination, and submit issues or
comments in writing;
• If the Adverse Benefit Determination is based on the lack of Medical Necessity of a particular service or the
Experimental or Investigational limitations and exclusions or other similar exclusions or limitations, the
Covered Plan Participant may request, free of charge, an explanation of the scientific or clinical judgment
relied upon, if any, for the determination, that applies the terms of the Monroe County Group Health Plan
Document to the Covered Plan Participant's medical circumstances:
• During the review process, the services in question will be reviewed without regard to the decision reached
in the initial determination;
• Wells Fargo TPA may consult with appropriate Physicians, as necessary;
• An independent medical consultant who reviews a Covered Plan Participant's Adverse Benefit
Determination on behalf of Wells Fargo Third Party Administrator will be identified upon request; and
• If the Covered Plan Participant's claim is a Claim Involving Urgent Care, the Covered Plan Participant may
request an expedited appeal orally or in writing in which case all necessary information on review may be
transmitted between the Covered Plan Participant and Wells Fargo TPA by telephone, facsimile or other
available expeditious method.
Timing of Appeal Review on Adverse Benefit Determinations by Wells Fargo TPA
Wells Fargo TPA will review a Covered Plan Participant's appeal of an Adverse Benefit Determination and
communicate the decision in accordance with the following time frames:
• Pre - Service Claims — within 30 days of the receipt of the Covered Plan Participant's appeal;
• Post - Service Claims —within 60 days of the receipt of the Covered Plan Participant's appeal;
• Claims Involving Urgent Care (and requests to extend concurrent care services made within 24 hours prior
to the termination of the services)- within 72 hours of receipt of the Covered Plan Participant's request. If
Claims Processing 18-6
additional information is necessary Wells Fargo TPA will notify the Covered Plan Participant within 24
hours and Wells Fargo TPA must receive the requested additional information within 48 hours of the
request. After Wells Fargo TPA receives the additional information, Wells Fargo TPA will have an
additional 48 hours to make a determination.
Note: The nature of a claim for services (i.e., whether it is "urgent care" or not) is judged as of the time of the
benefit determination on review, not as of the time the service was initially reviewed or provided.
Submit appeals of Adverse Benefit Determinations to:
Wells Fargo Third Party Administrator
P. O. Box 366
Charleston, WV 25322
Additional Claims Processing Provisions
1. Release of Information/ Cooperation:
In order to process claims, Wells Fargo TPA and /or the Monroe County Group Health Plan Administrator
may need certain information, including information regarding other health care coverage the Covered Plan
Participant may have. The Covered Plan Participant must cooperate with the Monroe County Group
Health Plan Administrator and /or Wells Fargo TPA's effort to obtain such information by, among other
ways, signing any release of information form at the request of Wells Fargo TPA. Failure by the Covered
Plan Participant to fully cooperate with Wells Fargo TPA and /or the Monroe County Group Health Plan
Administrator may result in a denial of the pending claim.
2. Physical Examination:
In order to make coverage and benefit decisions, the Monroe County Group Health Plan Administrator
may, at its expense, require the Covered Plan Participant to be examined by a health care Provider of the
Monroe County Group Health Plan Administrator's choice as often as is reasonably necessary while a claim
is pending. Failure by the Covered Plan Participant to fully cooperate with such examination shall result in a
denial of the pending claim.
3. Legal Actions:
No legal action arising out of or in connection with coverage under the Monroe County Group Health Plan
Document may be brought against the Monroe County Group Health Plan Administrator within the 60 -day
period following receipt of the completed claim as required herein. Additionally, no such action may be
brought after expiration of the applicable statue of limitations.
4. Fraud, Misrepresentation or Omission in Applying for Benefits:
Wells Fargo TPA relies on the information provided on the itemized statement and the claim form when
processing a claim. All such information, therefore, must be accurate, truthful and complete. Any
fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect information may
result, in addition to any other legal remedy Wells Fargo TPA and /or the Monroe County Group Health
Plan Administrator may have, in denial of the claim or cancellation or rescission of the Covered Plan
Participant's coverage.
Claims Processing 18-7
5. Explanation of Benefits Form:
All claims decisions, including denial and claims review decisions, will be communicated to the Covered
Plan Participant in writing either on an explanation of benefits form or some other written correspondence.
This form may indicate:
a) the specific reason or reasons for the Adverse Benefit Determination;
b) 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:
c) a description of any additional information that would change the initial determination and why that
information is necessary;
d) a description of the applicable Adverse Benefit Determination review procedures and the time limits
applicable to such procedures; and
e) 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 they
can obtain the specific explanation of the scientific or clinical judgment for the determination.
6. Circumstances Beyond the Control of Wells Fargo TPA:
To the extent that natural disaster, war, riot, civil insurrection, epidemic, or other emergency or similar event
not within the control of Wells Fargo TPA, results in facilities, personnel or financial resources of Wells
Fargo TPA being unable to process claims for Covered Services, Wells Fargo TPA will have no liability or
obligation for any delay in payment of claims for Covered Services, except that Wells Fargo TPA will make
a good faith effort to make payment for such services, taking into account the impact of the event. For the
purposes of this paragraph, an event is not within the control of Wells Fargo TPA if Wells Fargo TPA
cannot effectively exercise influence or dominion over its occurrence or non - occurrence.
Claims Processing 18-8
SECTION 19 - GENERAL PROVISIONS
Access to Information
Wells Fargo TPA and Monroe County Group Health Plan Administrator have the right to receive, from a Covered
Plan Participant or Covered Plan Participant's Provider rendering Service to a Covered Plan Participant information
that is reasonably necessary, as determined by Wells Fargo TPA and the Monroe County Group Health Plan
Administrator, in order to administer the coverage and benefits provided, subject to all applicable confidentiality
requirements listed below. By accepting coverage, Covered Plan Participants authorize every heath care Provider
who renders Services to a Covered Plan Participant to disclose to Wells Fargo TPA and the Monroe County Group
Health Plan Administrator or to affiliated entities, upon request, all facts, records, and reports pertaining to the
Covered Plan Participant's care, treatment, and physical or mental Condition, and to permit Wells Fargo TPA
and /or the Monroe County Group Health Plan Administrator to copy any such records and reports so obtained.
Right to Receive Necessary Information
In order to administer coverage and benefits, Wells Fargo TPA or the Monroe County Group Health Plan
Administrator may, without consent of, or notice to, any person, plan, or organization, obtain from any person,
plan, or organization any information with respect to any person covered under the Monroe County Group Health
Plan Document or applicant for enrollment which Wells Fargo TPA or the Monroe County Group Health Plan
Administrator deem to be necessary.
Right to Recovery
Whenever the Monroe County Group Health Plan has made payments in excess of the maximum provided under
the Monroe County Group Health Plan Document, Wells Fargo TPA or the Monroe County Group Health Plan
Administrator will have the right to recover any such payments, to the extent of such excess, from a Covered Plan
Participant or any person, plan, or other organization that received such payments.
Compliance with State and Federal Laws and Regulations
The terms of coverage and benefits to be provided under the Monroe County Group Health Plan Document shall
be deemed to have been modified and shall be interpreted so as to comply with applicable state and federal laws
and regulations dealing with benefits, eligibility, enrollment, termination, or other rights and duties.
Confidentiality
Except as otherwise specifically provided herein, and except as may be required in order for the Monroe County
Group Health Plan to administer coverage and benefits, specific medical information concerning a Covered Plan
Participant, received by Providers, shall be kept confidential by the Monroe County Group Health Plan
Administrator in conformity with applicable law. Such information may be disclosed to third parties for use in
connection with bona fide medical research and education, or as reasonably necessary in connection with the
administration of coverage and benefits, specifically including Wells Fargo TPA's quality assurance. Additionally,
Wells Fargo TPA and /or Monroe County Group Health Plan Administrator may disclose such information to
entities affiliated with it or other persons or entities it utilizes to assist in providing coverage, benefits or services
under the Monroe County Group Health Plan Document. Further, any documents or information which are
General Provisions 19-1
properly subpoenaed in a judicial proceeding, or by order of a regulatory agency, shall not be subject to this
provision.
Wells Fargo TPA's arrangements with a Provider may require that it release certain claims and medical information
about Covered Plan Participant s covered under the Monroe County Group Health Plan Document to that
Provider even if treatment has not been sought by or through that Provider. By accepting coverage, the Covered
Plan Participant hereby authorizes Wells Fargo TPA to release to Providers claims information, including related
medical information, pertaining to a Covered Plan Participant in order for any such Provider to evaluate a Covered
Plan Participant's financial responsibility under the Monroe County Group Health Plan Document.
Benefit Booklet
All Covered Plan Participant's have been provided with the Monroe County Group Health Plan Document and an
Identification Card(s) as evidence of coverage under the Monroe County Group Health Plan.
Cooperation Required of All Covered Plan Participants
All Covered Plan Participants must cooperate with Wells Fargo TPA and the Monroe County Group Health Plan
Administrator, and must execute and submit any consents, releases, assignments, and other documents requested in
order to administer, and exercise any rights hereunder. Failure to do so may result in the denial of claims and will
constitute grounds for termination for cause (See the Termination of an Individual's Coverage for Cause subsection
in the Termination of Coverage section).
Non - Waiver of Defaults
Any failure by Wells Fargo TPA or the Monroe County Group Health Plan Administrator at any time, or from time
to time, to enforce or to require in strict adherence to any of the terms or conditions described herein, will in no
event constitute a waiver of any such terms or conditions. Further, it will not affect Wells Fargo TPA's or Monroe
County Group Health Plan Administrator's right at any time to enforce any terms or conditions under the Monroe
County Group Health Plan Document.
Notices
Any notice required or permitted hereunder will be deemed given if hand delivered or if mailed by United States
Mail, postage prepaid, and addressed as listed below. Such notice will be deemed effective as of the date delivered
or so deposited in the mail.
To Wells Fargo Third Party Administrator: The address printed on the Identification Card.
To a Covered Plan Participant: The latest address provided by the Covered Plan Participant or to the address on
the latest Enrollment Form actually delivered to the Benefits Office.
All Covered Plan Participants must notify the Monroe County Group Health Plan Administrator (Benefits
Office) immediately of any address change.
If to Monroe County Group Health Plan Administrator: To the address provided in the General Plan Information
Section.
General Provisions 19-2
Obligations Upon Termination
Upon termination of a Covered Plan Participant's coverage for any reason, there will be no further liability or
responsibility to the Covered Plan Participant under the Monroe County Group Health Plan, except as specifically
described herein.
Promissory Estoppel
No oral statements, representations, or understanding by any person can change, alter, delete, add or otherwise
modify the express written terms of the Monroe County Group Health Plan Document.
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:
http:// ahca .myflorida.com /SCHS /index.shtml or www. FloridaHealth Finder. gov
Third Party Beneficiary
The terms and provisions of the Monroe County Group Health Plan Document shall be binding solely upon, and
inure solely to the benefit of, Monroe County Board of County Commissioners and individuals covered under the
terms of the Monroe County Group Health Plan Document, and no other person shall have any rights, interest or
claims there under, or under the Monroe County Group Health Plan Document, or be entitled to sue for a breach
thereof as a third -party beneficiary or otherwise.
Notification of Plan Changes
Any proposed change to the Plan that would constitute a material reduction in benefits or change in cost to current
Covered Plan Participants that will be presented to the BOCC will be preceded by a two week written notice to the
affected Covered Plan Participants.
General Provisions 19-3
SECTION 20 - HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA)
Use and Disclosure of Protected Health Information (PHI)
The Plan Administrator, as the sponsor of the Monroe County Health Insurance Plan "Sponsor ", will use and
disclose protected health information (PHI) to the extent of and in accordance with the uses and disclosures
permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Sponsor
will use and disclose PHI for purposes related to health care treatment, payment for health care and health care
operations. The provisions of this section (and other provisions of the Plan relating to HIPAA privacy rules) shall
be effective on April 14, 2003, or such later date as may be provided by federal law or regulation.
Use and Disclosure of PHI for Treatment, Payment and Operations
The Sponsor may, without the consent or authorization of the Covered Plan Participant, use and disclose PHI for
health care treatment, health care payment, and health care operations, and other uses or disclosures to the full
extent permitted by regulations promulgated by the Secretary of Health and Human Services to implement HIPAA,
subject to more stringent state privacy laws which do not conflict with HIPAA (if any).
The Sponsor may also disclose PHI to such other persons and for such other purposes when authorized by the
Covered Plan Participant on a form and in a manner provided for in regulations promulgated by the Secretary of
Health and Human Services to implement HIPAA.
The Sponsor may also disclose summary health information to the BOCC or the Employer if requested for the
purpose of obtaining bids from health plans for providing health insurance coverage, or for modifying, amending or
terminating the Plan. The Sponsor may also disclose information on whether the individual is participating in the
group health plan.
With Respect to PHI, the Plan Agrees to Certain Conditions
The Sponsor agrees to:
Not use of further disclose PHI other than as permitted or required by the Plan document or as required by
law;
2. Ensure that any agents, including a subcontractor, to whom the Sponsor provides PHI, agrees to the same
restrictions and conditions that apply to the Sponsor with respect to such PHI;
3. Not use or disclose PHI for employment - related actions and decisions unless authorized by the Covered
Plan Participant;
4. Not use or disclose PHI in connection with any other benefit or employee benefit plan of the BOCC unless
authorized by the Covered Plan Participant;
5. Make PHI available to a Covered Plan Participant in accordance with HIPAA's access requirements;
6. Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;
Health Insurance Portability and Accountability Act (HIPAA) 20-1
7. Make available the information required to provide an accounting of disclosures;
8. Make internal practices, books and records relating to the use and disclosure of PHI available to the HHS
secretary for the purposes of determining the Plan's compliance with HIPAA; and
9. If feasible, return or destroy all PHI received that the BOCC still maintains in any form, and retain no
copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or
destruction if not feasible, limit further uses and disclosures to those purposes that make the return or
destruction infeasible).
Health Insurance Portability and Accountability Act (HIPAA) 20-2
SECTION 21 - DEFINITIONS
The following definitions are used in the Monroe County Group Health Plan Document. Other definitions may be
found in the particular section or subsection where they are used.
Accident means an unintentional, unexpected event, other than the acute onset of a bodily infirmity or disease,
which results in traumatic injury. This term does not include injuries caused by surgery or treatment for disease or
illness.
Accidental Dental Injury means an injury to sound natural teeth (not previously compromised by decay) caused
by a sudden, unintentional, and unexpected event or force. This term does not include injuries to the mouth,
structures within the oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a
disease or illness.
Active Work means active full time performance by an Eligible Employee of all customary duties of his or her
occupation at the Employer location or another location of business to which the Employer requires the Eligible
Employee to travel. An Eligible Employee shall be deemed "Active at Work" on each day of regular paid vacation,
and on a regular nonworking day on which the Eligible Employee is not disabled, provided the Eligible Employee
was actively at work on the last preceding working day.
Adverse Benefit Determination means any denial, reduction or termination of coverage, benefits, or payment (in
whole or in part) under the Monroe County Group Health Plan Document with respect to a Pre - Service Claim or a
Post - Service Claim. Any reduction or termination of coverage, benefits, or payment in connection with a
Concurrent Care Decision, as described in this section, shall also constitute an Adverse Benefit Determination.
Allowed Amount means the maximum amount upon which payment will be based for Covered Services
established in accordance with the applicable agreements between the Monroe County Group Health Plan and the
PPO Networks. The Allowed Amount may be changed at any time without notice to Covered Plan Participant or
their consent.
Ambulance means a ground or water vehicle, airplane or helicopter properly licensed pursuant to Chapter 401 of
the Florida Statutes, or a similar applicable law in another state intended to be used for transportation of sick or
injured persons requiring or likely to require medical attention during transport.
Ambulatory Surgical Center means a facility properly licensed pursuant to Chapter 395 of the Florida Statutes, or
similar applicable law of another state, the primary purpose of which is to provide elective surgical care to a patient,
admitted to, and discharged from such facility within the same working day.
Artificial Insemination (AI) means a medical procedure in which sperm is placed into the female reproductive
tract by a qualified health care provider for the purpose of producing a pregnancy.
Birth Center means a facility or institution, other than a Hospital or Ambulatory Surgical Center, which is properly
licensed pursuant to Chapter 383 of the Florida Statutes, or a similar applicable law or another state, in which births
are planned to occur away from the mother's usual residence following a normal, uncomplicated, low -risk
pregnancy.
Bone Marrow Transplant means human blood precursor cells administered to a patient to restore normal
hematological and immunological functions following ablative or non - ablative therapy with curative or life-
Definitions 21-1
prolonging intent. Human blood precursor cells may be obtained from the patient in an autologous transplant, or
an allogeneic transplant from a medically acceptable related or unrelated donor, and may be derived from bone
marrow, the circulating blood, or a combination of bone marrow and circulating blood. If chemotherapy is an
integral part of the treatment involving bone marrow transplantation, the term "Bone Marrow Transplant" includes
the transplantation as well as the administration of chemotherapy and the chemotherapy drugs.
Calendar Year begins January 1St and ends December 31St
Cardiac Therapy means Health Care Services provided under the supervision of a Physician, or an appropriate
Provider trained for Cardiac Therapy, for the purpose of aiding in the restoration of normal heart function in
connection with a myocardial infarction, coronary occlusion or coronary bypass surgery.
Certified Nurse Midwife means a person who is licensed pursuant to Chapter 464 of the Florida Statutes, or a
similar applicable law of another state, as an advanced registered nurse practitioner and who is certified to practice
midwifery by the American College of Nurse Midwives.
Certified Registered Nurse Anesthetist means a person who is a properly licensed nurse who is certified
advanced registered nurse practitioner within the nurse anesthetist category pursuant to Chapter 464 of the Florida
Statutes, or a similar applicable law of another state.
Claim Involving Urgent Care means any request or application for coverage or benefits for medical care or
treatment that has not yet been provided with respect to which the application of time periods for making non -
urgent care benefit determinations: (1) could seriously jeopardize the life or health or a Covered Plan Participant's
ability to regain maximum function; or (2) in the opinion of a Physician with knowledge of the Covered Plan
Participant's Condition, would subject the Covered Plan Participant to severe pain that cannot be adequately
managed without the proposed Services being rendered.
Claims Administrator means the individual or entity that processes claims, provides certain financial services,
provides reports and makes initial benefit determinations subject to the Monroe County Group Health Plan
Document. It does not fund or insure claim payments or bear any financial risk with regard to The Plan's expenses.
Currently, the Claims Administrator is Wells Fargo Third Party Administrator. The Plan has the discretion to
change its Claims Administrator at any time.
Coinsurance means the Covered Plan Participant's share of health care expenses for Covered Services. After the
Deductible requirement is met, a percentage of the Allowed Amount will be paid for Covered Services, as listed in
the Schedule of Benefits. This percentage is the Coinsurance for which the Covered Plan Participant is responsible
Concurrent Care Decision means a decision by Wells Fargo Third Party Administrator to deny, reduce, or
terminate coverage, benefits, or payment (in whole or in part) with respect to a course of treatment to be provided
over a period of time, or a specific number of treatments, if we had previously approved or authorized in writing
coverage, benefits or payment for that course of treatment or number of treatments.
Condition means a disease, illness, ailment, injury, or pregnancy.
Covered Employee/ Retiree means an Eligible Employee or an Eligible Retiree who is enrolled, and actually
covered, under the Monroe County Group Health Plan Document.
Covered Plan Participant means an Eligible Employee or other individual who meets and continues to meet all
applicable eligibility requirements and who is enrolled, and actually covered, under the Monroe County Group
Health Plan Document.
Definitions 21-2
Covered Services means those Health Care Services which meet the criteria listed in the "Covered Services"
section.
Creditable Coverage means health care you have had in the past, such as coverage under a group health plan
(including COBRA continuation coverage), an HMO, an individual health insurance policy, Medicare or Medicaid,
and this prior coverage was not interrupted by a break in coverage of 63 days or more. The time period of this
prior coverage must be applied toward any pre - existing condition exclusion imposed by the Plan.
Custodial or Custodial Care means care that serves to assist an individual in the activities of daily living, such as
assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of
special diets, and supervision of medication that usually can be self - administered or administered by a home care
giver. Custodial Care essentially is personal care that does not require the continuing attention of trained medical or
paramedical personnel. In determining whether a person is receiving Custodial Care, consideration is given to the
frequency, intensity and level of care and medical supervision required and furnished. A determination that care
received is Custodial is not based on the patient's diagnosis, type of Condition, degree of functional limitation, or
rehabilitation potential.
Deductible means the amount of charges, up to the Allowed Amount, for Covered Services that are the Covered
Plan Participants responsibility. The term, Deductible, does not include any amounts in excess of the Allowed
Amount, or any Coinsurance /Copay amounts, if applicable, that are the responsibility of the Covered Plan
Participant.
Detoxification means a process whereby an alcohol or drug intoxicated, or alcohol or drug dependent, individual is
assisted through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or
drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician
or Psychologist, while keeping the physiological risk to the individual at the minimum.
Diabetes Educator means a person who is properly certified pursuant to Florida law, or a similar applicable law of
another state, to supervise diabetes outpatient self - management training and educational services.
Dietitian means a person who is properly licensed pursuant to Florida law or a similar applicable law of another
state to provide nutrition counseling or diabetes outpatient self - management services.
Durable Medical Equipment means equipment furnished by a supplier or a Home Health Agency that: 1) can
withstand repeated use; 2) is primarily and customarily used to serve a medical purpose; 3) not for comfort or
convenience; 4) generally is not useful to an individual in the absence of a Condition; and 5) is appropriate for use
in the home.
Effective Date means, with respect to individuals covered under the Monroe County Group Health Plan
Document, 12:01 a.m. on the date Monroe County Group Health Plan Administrator specifies that the coverage
will commence as further described in the "Enrollment & Effective Date of Coverage" section of the Monroe
County Group Health Plan Document.
Eligible Dependent means an individual who meets and continues to meet all of the eligibility requirements
described in the Eligibility Requirements for Dependent(s) subsection of the "Eligibility for Coverage" section in
the Monroe County Group Health Plan Document, and is eligible to enroll as a Covered Plan Participant.
Refer to the "Eligibility for Coverage" section for limits on eligibility.
Definitions 21-3
Eligible Employee/ Retiree means an individual who meets and continues to meet all of the eligibility
requirements described in the Eligibility Requirements for Covered Employee subsection of the Eligibility for
Coverage section in the Monroe County Group Health Plan Document and is eligible to enroll as a Covered Plan
Participant. Any individual who is an Eligible Employee is not a Covered Plan Participant until such individual has
actually enrolled with, and been accepted for coverage as a Covered Plan Participant by the Monroe County Group
Health Plan Administrator.
Employer means the Monroe County Board of County Commissioners; Clerk of the Circuit Court; Land
Authority; Property Appraiser; Sheriff's Office; Supervisor of Elections; Tax Collector.
Endorsement means an amendment to the Monroe County Group Health Plan Document.
Experimental or Investigational means any evaluation, treatment, therapy, or device which involves the
application, administration or use, of procedures, techniques, equipment, supplies, products, remedies, vaccines,
biological products, remedies, vaccines, biological products, drugs, pharmaceuticals, or chemical compounds if, as
determined solely by Wells Fargo TPA or the Monroe County Group Health Plan Administrator:
1. such evaluation, treatment, therapy, or device cannot be lawfully marketed without approval of the United
States Food and Drug Administration of the Florida Department of Health and approval for marketing has
not, in fact, been given at the time such is furnished to a Covered Plan Participant; or
2. such evaluation, treatment, therapy, or device is provided pursuant to a written protocol which describes as
among its objectives the following: determinations of safety, efficacy, or efficacy in comparison to the
standard evaluation, treatment, therapy, or device; or
3. such evaluation, treatment, therapy, or device is delivered or should be delivered subject to the approval and
supervision of an institutional review board or other entity as required and defined by federal regulations; or
4. creditable scientific shows that such evaluation, treatment, therapy, or device is the subject of an ongoing
Phase I or II clinical investigation, or the experimental or research arm of the Phase III clinical investigation,
or under study to determine: maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared
with the standard means for treatment or diagnosis of the Condition in question; or
5. creditable scientific shows that the consensus of opinion among experts is that further studies, research, or
clinical investigations are necessary to determine: maximum tolerated dosage(s), toxicity, safety, efficacy, or
efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; or
6. creditable scientific shows that such evaluation, treatment, therapy, or device has not been proven safe and
effective for treatment of the Condition in question, as evidenced in the most recently published Medical
Literature in the United States, Canada, or Great Britain, using Generally Accepted Standards of Medical
Practice; or
7. there is no consensus among practicing Physicians that the treatment, therapy, or device is safe and effective
for the Condition in question; or
8. such evaluation, treatment; therapy, or device is not the standard treatment, therapy, or device utilized by
practicing Physicians in treating other patients with the same or similar Condition.
"Credible scientific" shall mean (as determined by Wells Fargo TPA or Monroe County Group Health Plan
Administrator):
Definitions 21-4
1. records maintained by Physicians or Hospitals rendering care or treatment to a Covered Plan Participant or
other patients with the same or similar Condition;
2. reports, articles, or written assessments in authoritative medical and scientific literature published in the
United States, Canada, or Great Britain;
3. published reports, articles, or other literature of the United States Department of Health and Human
Services or the United States Public Health Service, including any of the National Institutes of Health, or
the United States Office of Technology Assessment;
4. the written protocol or protocols rely upon by the treating Physician or institution or the protocols of
another Physician or institution studying substantially the same evaluation, treatment, therapy or device;
5. the written informed consent used by the treating Physician or institution or by another Physician or
institution studying substantially the same evaluation, treatment, therapy, or device; or
6. the records (including any reports) of any institutional review board of any institution which has reviewed
the evaluation, treatment, therapy, or device for the Condition in question.
Note: Health Care Services which are determined by Wells Fargo TPA or the Monroe County Group
Health Plan Administrator to be Experimental or Investigational are excluded (see the "Covered Services"
section)in determining whether a Health Care Service is Experimental or Investigational. Wells Fargo
TPA or Monroe County Group Health Plan Administrator may also rely on the predominant opinion
among experts, as expressed in published authoritative literature, that usage of a particular evaluation,
treatment, therapy, or device should be substantially confined to research settings or that further studies
are necessary in order to define safety, toxicity, effectiveness, or effectiveness compared with standard
alternatives.
Foster Child means a person who is placed in a Covered Plan Participant's residence and care under the Foster
Care Program by the Florida Department of Health & Rehabilitative Services in compliance with Florida Statutes or
by a similar regulatory agency of another state in compliance with that state's applicable laws.
Generally Accepted Standards of Medical Practice means standards that are based on credible scientific
evidence published in peer- reviewed medical literature generally recognized by the relevant medical community,
Physician Specialty Society recommendations, and the views of Physicians practicing in relevant clinical areas and
any other relevant factors.
Gestational Surrogate means a woman, regardless of age, who contract, orally or in writing, to become pregnant
by means of assisted reproductive technology without the use of an egg from her body.
Gestational Surrogacy Contract or Arrangement means an oral or written agreement, regardless of the state or
Jurisdiction where executed, between the Gestational surrogate and the intended parent or parents.
Health Care Services or Services includes treatments, therapies, devices, procedures, techniques, equipment,
supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, chemical compounds, and other
services rendered or supplied by, or at the direction of, Providers.
Home Health Agency means a properly licensed agency or organization which provides health services in the
home pursuant to Chapter 400 of the Florida Statutes, or similar applicable law of another state.
Definitions 21-5
Home Health Care or Home Health Care Services means Physician- directed professional, technical and related
medical and personal care Services provided on an intermittent or part -time basis directly by (or indirectly through)
a Home Health Agency in the Covered Plan Participant's home or residence. For purposes of this definition, a
Hospital, Skilled Nursing Facility, nursing home or other facility will not be considered an individual's home or
residence.
Hospice means a public agency or private organization which is duly licensed by the State of Florida under
applicable law, or a similar applicable law of another state, to provide hospice services. In addition, such licensed
entity must be principally engaged in providing pain relief, symptom management, and supportive services to
terminally ill persons and their families.
Hospital means a facility properly licensed pursuant to Chapter 395 of the Florida Statues, or a similar applicable law
of another state, that: offers services which are more intensive than those required for room, board, personal
services and general nursing care; offers facilities and beds for use beyond 24 hours; and regularly makes available at
least clinical laboratory services, diagnostic x -ray services and treatment facilities for surgery or obstetrical care or
other definitive medical treatment of similar extent.
The term Hospital does not include: an Ambulatory Surgical Center; a Skilled Nursing Facility; a stand -alone
Birthing Center; a Psychiatric Facility, a Substance Abuse Facility; a convalescent, rest or nursing home; or a facility
which primarily provides Custodial, educational, or Rehabilitative Therapies.
Note: If services specifically for the treatment of a physical disability are provided in a licensed Hospital
which is accredited by the Joint Commission on the Accreditation of Health Care Organizations, the
American Osteopathic Association, or the Commission on the Accreditation of Rehabilitative Facilities,
the payment for these services will not be denied solely because such Hospital lacks major surgical
facilities and is primarily of a rehabilitative nature. Recognition of these facilities does not expand the
scope of Covered Services. It only expands the setting where Covered Services can be performed for
coverage purposes.
Identification (ID) Card means the card(s) issued to Covered Plan Participants under the Monroe County Group
Health Plan. The card is not transferable to another person. Possession of such card in no way guarantees that a
particular individual is eligible for, or covered under the Monroe County Group Health Plan.
In- Network means, when used in reference to Covered Services, the level of benefits payable to an In- Network
Provider as designated on the Schedule of Benefits under the heading "In- Network ". Otherwise, In- Network
means, when used in reference to a Provider, that, at the time Covered Services are rendered, the Provider is an In-
Network Provider under the terms of the Monroe County Group Health Plan Document.
Licensed Practical Nurse means a person properly licensed to practice practical nursing pursuant to Chapter 464
of the Florida Statutes, or similar applicable law of another state.
Massage Therapist means a person properly licensed to practice Massage, pursuant to Chapter 480 of the Florida
Statutes, or a similar applicable law of another state.
Mastectomy means the removal of all or part of the breast for Medically Necessary reasons as determined by a
Physician.
Medical Literature means scientific studies published in a United States peer- reviewed national professional
journal.
Definitions 21-6
Medically Necessary or Medical Necessity means that, with respect to a Health Care Service, a Physician,
exercising prudent clinical judgment, provided the Health Care Service to the Covered Plan Participant for the
purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that the
Health Care Service was:
1. in accordance with General Accepted Standards of Medical Practice;
2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the
Covered Plan Participant's illness, injury or disease; and
3. not primarily for the Covered Plan Participants convenience, or that of the Covered Plan Participant's
Physician or other health care Provider, and not more costly that an alternative Service or sequence of
Services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or
treatment of the Covered Plan Participant's illness.
Medicare means the federal health insurance provided under Tide XVIII of the Social Security Act and all
amendments thereto.
Mental Health Professional means a person properly licensed to provided mental health Services, pursuant to
Chapter 491 of the Florida Statutes, or a similar applicable law of another state. This professional may be a clinical
social worker, mental health counselor or marriage and family therapist. A Mental Health Professional does not
include members of any religious denomination who provide counseling services.
Mental and Nervous Disorder means any disorder listed in the diagnostic categories of the Internal Classification
of Disease, Ninth Edition, Clinical Modification (ICD -9 CM), or their equivalents in the most recently published
version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, regardless
of the underlying cause, or effect, of the disorder.
Midwife means a person properly licensed to practice midwifery pursuant to Chapter 467 of the Florida Statues, or a
similar applicable law of another state.
Morbid Obesity means a condition diagnosed by a Physician in which the patient who is over 18 years old and has
completed bone growth meets one (1) or more of the following criteria:
• A body mass index (BMI) exceeds forty (40);
• A body mass index is greater than thirty -five (35) in conjunction with severe co- morbidities that are likely to
reduce life expectancy (e.g., cardiopulmonary complications, severe diabetes, severe sleep apnea; medically
refractory hypertension);
• A body weight of approximately 100 lbs. over ideal weight as provided in the Metropolitan Life and Weight
table.
Occupational Therapist means a person properly licensed to practice Occupational Therapy as pursuant to
Chapter 468 of the Florida Statutes, or a similar applicable law of another state.
Occupational Therapy means a treatment that follows an illness or injury and is designed to help a patient learn to
use a newly restored or previously impaired function.
Definitions 21-7
Orthotic Device means any rigid or semi -rigid device needed to support a weak or deformed body part or restrict
or eliminate body movement.
Out -of- Network means, when used in reference to Covered Services, the level of benefits payable to an Out -of-
Network Provider as designated on the Schedule of Benefits under the heading "Out -of- Network ". Otherwise,
Out -of- Network means, when used in reference to a Provider, that, at the time Covered Services are rendered, the
Provider is not an In- Network Provider under the terms of the Monroe County Group Health Plan Document.
Outpatient Facility means any licensed facility which renders, through providers properly licensed pursuant to
Florida law or the similar law or laws of another state: outpatient physical therapy; outpatient speech therapy;
outpatient occupational therapy; outpatient cardiac rehabilitation therapy; and outpatient Massage for the primary
purpose of restoring or improving a bodily function impaired or eliminated by a Condition. Further, such an entity
must meet Wells Fargo Third Party Administrator criteria for eligibility as an Outpatient Facility. The term
Outpatient Facility, as used herein, shall not include any the office of any Physician, Midwife, Physical Therapist,
Occupational Therapist; any Hospital, including a general acute care Hospital, or any separately organized unit of a
Hospital, which provides comprehensive medical rehabilitation inpatient services, or rehabilitation outpatient
services, including, but not limited to, a Class III "specialty rehabilitation hospital" described in Chapter 59A, Florida
Administrative Code or the similar law or laws of another state.
Pain Management includes, but is not limited to, Services for pain assessment, medication, physical therapy,
biofeedback, and /or counseling. Pain rehabilitation programs are programs featuring multidisciplinary Services
directed toward helping those with chronic pain to reduce or limit their pain.
Partial Hospitalization means treatment in which an individual receives at least seven hours of institutional care
during a portion of a 24 -hour period and returns home or leaves the treatment facility during any period in which
treatment is not scheduled. A Hospital shall not be considered a "home" for purposes of this definition.
Physical Therapist means a person properly licensed to practice Physical Therapy pursuant to Chapter 486 of the
Florida Statutes, or a similar applicable law of another state.
Physician means any individual who is properly licensed by the state of Florida, or a similar applicable law of
another state, as a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor
of Chiropractic (D.C.), Doctor of Dental Surgery or Dental Medicine (D.D.S. or D.M.D.), or Doctor of Optometry
(O.D.)
Physician Assistant means a person properly licensed pursuant to Chapter 458 of the Florida Statutes, or a similar
applicable law of another state to perform medical services delegated by the supervising Physician.
Plan means the Monroe County Group Health Plan Document.
Plan Administrator means the Monroe County Board of County Commissioners.
Prosthetic Device means a device designed or manufactured by a person or entity that is properly licensed, if
applicable, under Florida law, or a similar applicable law of another state, to provide services consisting of the
design and fabrication of medical devices such as braces, splints, and artificial limbs prescribed by a Physician.
Provider means any facility, person or entity recognized for payment by Wells Fargo Third Party Administrator
under the Monroe County Group Health Plan Document.
Psychologist means a person properly licensed to practice psychology pursuant to Chapter 490 of the Florida
Statutes, or a similar applicable law of another state.
Definitions 21-8
Registered Domestic Partner means a person who has established a Domestic Partnership with a Covered Plan
Participant according to Monroe County Board of County Commissioners Resolution No. 081 -1998.
Registered Nurse means a person properly licensed to practice professional nursing pursuant to Chapter 464 of
the Florida Statutes, or a similar applicable law of another state.
Skilled Nursing Facility means an institution or part thereof which meets Wells Fargo Third Party Administrator's
criteria for eligibility as a Skilled Nursing Facility and which: 1) is licensed as a Skilled Nursing Facility by the state
of Florida or a similar applicable law of another state; and 2) is accredited as a Skilled Nursing Facility by the Joint
Commission on Accreditation of Healthcare Organizations or recognized as a Skilled Nursing Facility by the
Secretary of Health and Human Services of the United States under Medicare, unless such accreditation or
recognition requirement has been waived by Wells Fargo Third Party Administrator.
Speech Therapist means a person properly licensed to practice Speech Therapy pursuant to Chapter 468 of the
Florida Statutes, or similar applicable law of another state.
Substance Abuse Facility means a facility properly licensed under Florida law, or a similar applicable law of
another state, to provide necessary care and treatment for Substance Dependency. For the purposes of the Monroe
County Group Health Plan Document a Substance Abuse Facility is not a Hospital or a Psychiatric Facility, as
defined herein.
Substance Dependency means a Condition where a person's alcohol or drug use injures his or her health;
interferes with his or her social or economic functioning; or causes the individual to lose self - control.
Urgent Care means care offered at a facility properly licensed that: 1) is available to provide Services to patients at
least 60 hours per week with at least twenty -five (25) of those available hours after 5:00 p.m. on weekdays or on
Saturday or Sunday; 2) posts instructions for individuals seeking Health Care Services, in a conspicuous public
place, to where to obtain such Services when the Urgent Care center is closed; 3) employs or contracts with at least
one or more Board Certified or Board Eligible Physicians and Registered Nurses (RNs) who are physically present
during all hours of operation. Physicians, RNs, and other medical professional staff must have appropriate training
and skills for the care of adults and children; and 4) maintains and operates basic diagnostic radiology and
laboratory equipment in compliance with applicable state and /or federal laws and regulations.
For the purposes of the Monroe County Group Health Plan Document, an Urgent Care center is not a Hospital,
Psychiatric Facility, Substance Abuse Facility, Skilled Nursing Facility or Outpatient Rehabilitation Facility.
Waiting Period means the length of time established by the Monroe County Group Health Plan Document which
must be met by an individual before that individual becomes eligible for coverage under the Monroe County Group
Health Plan Document.
Definitions 21-9
BOARD OF COUNTY COMMISSIONERS
MONROE COUNTY GROUP HEALTH PLAN
Each provision, each benefit, each page in the Plan Document for which the pages
attached have been reviewed and approved by the undersigned.
This Plan Document is Effective January 1, 2010, except as otherwise noted.
Name: Board of County Commissioners — Monroe County
Ap rov d lay:
I
Monroe County Board of County Commissioners
Group Health Plan Document
.Amendment #1
THIS AMENDMENT to the Monroe County Board of County Commissioners
Group Health Plan Document (the "Plan Sponsor ") effective this .1" day of August, 2010.
WHEREAS, the Plan Sponsor reserves the right to amend the Plan at any time; and
WHEREAS, this Amendment has been duly adopted by the Plan Sponsor to
incorporate the following provisions.
NOW, THEREFORE, pursuant to the Plan amendment provision, the Plan shall be
amended as follows:
Page 1 -1
Amend Section 1— Schedule of Benefits to read as follows:
B. OFFICE SERVICES
Benefit Description
In- Network
flat - of - Network
Physician Office Visits
100% of Allowed
45%
Amount, no Deductible
Of Allowed Amount
The co -pay benefit includes physician office
after a $20 co - pay
visit for routine care, diagnosis and treatment
of an illness or non -work related injury. The
benefit does not include diagnostics, surgical
procedures, Hospital services, obstetric care,
chemo /radiation, speech or physical therapy.
The benefit does not include chiropractors (see
Benefit Maximums Spinal Manipulations and
Massage Therapy).
Adult Wellness — Refer to Benefit Maximums
$400 Maximum Allowed
$400 Maximum
After $20 co-p
Allowed
Office Diagnostics
75%
45%
filled with or without an office visit)
of Allowed Amount
of Allowed Amount
Durable Medical Equipment, Prosthetics and
75%
45%
Orthotics
of Allowed Amount
of Allowed Am ount
Note: A Covered Plan Participant should verify a Provider's participation status prior to receiving
Health Care Services. To verify a Provider's participation status just access any one of our three
PPO Networks through our web site at
tLil)_ /iy_c> i� occt) ti,k- 'rtLi:llt �w ni-�ail.i - i t,' I'�I , c s .�yIo ii o e(,'ol '1 G1° <>LmI sL rapc e /ind x or contact the
Benefits Office at 305 - 292 -4579 or 305 - 292 -4446 for assistance.
1 of 2
Monroe County Board of County Commissioners
Group Health Plan Document
Amendment #1
Effective Au-oust 1, 2010
PASSED AND ADOPTED by the Board of County Comm f Monroe County, Florida.
at a regular meeting of said Board held on the r�l day of �;F 2010.
Mayor Sylvia Murphy
Yes
Mayor Pro Tem Heather Carruthers
Yes
Commissioner Kim Wigington
Yes
Commissioner George Neugent
Yes
Commissioner Mario Di Gennaro
Yes
zt-
(SEALIK
INY L. KOLHAGE, Clerk
By
Deputy Clerk
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By
Mayor/Chairperson
MONROZE ,:' i-'TTORNEY
4 PPRC ( }V�** . L7 A�S T 0 F �OR M:
CHRISTINE M. LIMBERT-BARROWS
ASSISTANT COUNTY ATTORNEY
Date
J
C4
W CZ)
2 of 2
Monroe County Board of County Commissioners
Group Health Plan Document
Amendment #2
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
NOW, THEREFORE, pursuant to the Plan amendment provisions, the Plan shall be
amended effective January 1, 2011 as follows:
1. Page 1 -2: The "Accumulated Total Lifetime Maximum Benefit" line item of Section
1 C of the Plan is amended to read as follows:
"Accumulated Total Lifetime Maximum Benefit Per Covered Participant (includes
medical care services & pharmaceuticals) .................. unlimited
2. Page 1 -2: The "Autism Spectrum Disorder" line item of Section 1 C of the Plan is
amended to read as follows:
"Autism Spectrum Disorder Per Covered Plan Participant Per Calendar Year ......
....... $36,000"
3. Page 4 -1: The Introduction section of Section 4 of the Plan is amended to read as
follows:
"Introduction
Covered Plan Participants when initially enrolled in the Plan will be subject to a Pre-
existing Condition exclusionary period, except for the following properly - enrolled
individuals: newborn or adopted dependents; and individuals under the age of 19. A
Covered Plan Participant with Creditable Coverage in effect for a continuous period
of 12 months or longer prior to initial enrollment will not be subject to a Pre - existing
Condition exclusionary period."
4. Page 7 -3: The Exclusion under the "Autism" section of Section 7 of the Plan is
amended to read as follows:
" Exclusion — The plan will not pay for Covered Services which exceed the annual
maximum for Autism Spectrum Disorder listed in the Schedule of Benefits."
5. 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 and who is not eligible to enroll in an eligible employer - sponsored
health plan other than a grandfathered health plan of a parent; or"
"2. on the date the Covered Dependent's coverage terminates for any reason;
a. As further clarification for purposes of this subsection, a Covered Dependent
child who has reached the end of the Calendar Year in which he or she
becomes 26, but who has not reached the end of the Calendar Year in which
the Covered Dependent child becomes 30 will lose coverage if the Covered
Dependent child incurs any of the following:
1. mamage;
ii. no longer resides in Florida or is no longer a full -time or part -time
student;
iii. obtains a dependent (e.g., through birth or adoption);
iv. obtains other coverage; or
V. on the date of termination of the Covered Employee's coverage. "
PASSED AND ADOPTED by the Board of County Commissioners of Monroe County,
Florida, at a regular meeting of said Board held on the 15th day of December , 2010.
6. Page 11 -1: Paragraph 2 of the "Termination of a Covered Dependent's Coverage"
subsection of Section 11 is amended to read as follows:
Mayor Heather Carruthers
Mayor Pro Tern David Rice
Commissioner George Neugeut
l ommissioner Rim Wigingtou
4 ` missioner Sylvia Murphy
, a
M
Cr
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fl
CD
Li..
LA —1
.t
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Deput Clerk
O
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Yes
Yes
Yes
Yes
Yes
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
MONR,qE COUNTY ATTORNEY
_ AP OV AS T/D
. ff RV:
NTHIA L. ALL
ASSIST T COUNTY ATTORNEY
ate ____,,_ j j- X - RD 16
Monroe 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
24 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 19* d ay of .Jan mry , 2411.
Mayor Heather Carruthers
Mayor Pro Tem David Rice
Commissioner George Neugent
Commissioner Sylvia Murphy
Commissioner Kim Wigington
t�
r`
Tf
Yes
Yes
Yes
Yes
Yes
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By:
May r /Chairperson
MO OE COUNTY ATTORNEY
ROV AS F M'
CYNTHIA L. HA L
ASSIS ANT COUNTY ATTORNEY
SECTION FOUR
MEDICAL BENEFITS CLAIMS ADMINISTRATION SERVICES
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Respond to questions immediately after the question.
Organization Name:
Primary Contact/Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Submit responses in Hard Copy and Electronic Version in a useable Microsoft
Word format.
1. Can network services be purchased independent of other services? If so, please
list any Networks from which you cannot administer claims.
2. Are rates guaranteed for three years (36 months)?
Rates are requested for year 1, year 2 and year 3. On years 2 & 3, a maximum or
cap is requested. Proposals submitted without maximums or cap for years 2 & 3 may
not receive the same consideration as those with a maximum or cap.
3. On what date did your organization enroll its first group in Florida for coverage and
for what type of coverage?
Type of Coverage Date
HMO
POS
PPO
Self- Funding
4. Provide the enrollment data (including all plans) requested below for the
organization submitting this Proposal:
Section Four — Claims Administration Services Page 1
a.) National Enrollment
11112008 1 11112009 1 11112010 1 11112011
Commercial Enrollment
Other Enrollment
Total Enrollment
b.) Florida Enrollment
li 1fi Fkzlil1;: =1111111115 1fi Fk*1*==1fi 1h*7i P)•1111111115 1fi 1h*7i `I
Commercial Enrollment
Other Enrollment
Total Enrollment
c.) South Florida (Monroe, Broward, Miami -Dade and Palm Beach Counties)
Enrollment
11112008 1 11112009 1 11112010 1 11112011
Commercial Enrollment
Other Enrollment
Total Enrollment
d.) Monroe County Enrollment
F - 1/11/2008 1/1/2009 1/1/2010 1/1/2011
Commercial Enrollment
Other Enrollment
Total Enrollment
5. What percent of your Florida enrollment in 2009 and 2010 is from public sector
clients? What percentage is Fully Insured vs. Self- Funded?
Florida Enrollment Total 2009 2010 % %
Enrollment % of % of Fully Self -
Public Public Insured Funded
Sector Sector
Commercial Enrollment
Other Enrollment
Total Enrollment
6. Provide NCQA, JCAHO, AAA and /or any other accreditation status that applies to
the medical and /or Behavioral Health plan(s) you are proposing. Provide a copy of
your accreditation letter(s) under TAB 1 of your proposal.
7. Will you allow Employee Assistance Programs (EAP) to be provided by another firm
at MCBCC's discretion? Yes No
Section Four — Claims Administration Services Page 2
8. Detail any mergers /acquisitions involving your organization which have occurred in
the last 12 -month period, and any which are planned for the next 12 to 24 months.
9. How do you track verbal and written complaints received by your organization?
10.Are you able to report the number and types of complaints (both written and
telephonic) received in a calendar year for all plan members (total population) and
MCBCC members specifically? Yes No
11. How many verbal and written complaints were received per 1,000 members during
2008, 2009 2010, and YTD for 2011 ?
Year Number per 1000
2008
2009
2010
2011
12. How are providers instructed to handle members who have not yet been issued
member ID cards?
13. What percentage of services requested were denied for medical necessity in 2008,
2009 and 2010? Of those denials, what percentage was appealed and
subsequently approved? Describe what types of services are most frequently
denied and why these services are denied.
14.Are the member grievances /appeals tracked and reported? Yes No If
yes, are you able to provide MCBCC with a report capturing the number and types of
grievances /appeals which are received from MCBCC members?
Yes No
15. Can your plan track and report on customer service activity? Yes No
16. Who is responsible for reviewing claim payment for correctness? Is this an internal
or external process? Is there a charge for this? Yes No If yes, what is
the cost?
17. Describe your hospital audit procedure. At what dollar amount would an audit be
initiated?
Section Four — Claims Administration Services Page 3
2008
2009
2010
% Denied
% Appealed
Subsequently
Approved
14.Are the member grievances /appeals tracked and reported? Yes No If
yes, are you able to provide MCBCC with a report capturing the number and types of
grievances /appeals which are received from MCBCC members?
Yes No
15. Can your plan track and report on customer service activity? Yes No
16. Who is responsible for reviewing claim payment for correctness? Is this an internal
or external process? Is there a charge for this? Yes No If yes, what is
the cost?
17. Describe your hospital audit procedure. At what dollar amount would an audit be
initiated?
Section Four — Claims Administration Services Page 3
18. Do you alert clients of claims in excess of a specified amount, prior to check
issuance?
19. Do your claims adjusters make telephone calls to claimants to obtain diagnosis
information, accident details, student status verification, etc.? If you do not provide
this service on a routine basis, can you provide it at an additional cost? If so, what is
the cost?
20. Can claimants talk to the claims adjusters directly? Or do claimants talk to customer
service representatives instead? What hours /days are the claims adjusters and /or
claims service representatives available?
21. Describe your training for claims processors. What is the average training time
before a claims processor is given full payment authorization?
22. What is the average tenure for your claims processors? For Supervisors?
23. Ad hoc reports shall be available upon request. Will there be an additional charge
for these reports? Yes No If yes, what is the cost?
24.1s your organization currently in compliance with Florida Office of Insurance
Regulation profitability and reserve requirements? Yes No . If no, have
you been required to submit a Corrective Action Plan? If yes, attach a copy of the
CAP.
25. Describe, in detail, your out -of -area coverage for traveling members, both within and
outside the United States. Describe your capabilities for negotiating fees with out -
of -area providers.
26. Does your plan cover members that utilize services offered through a walk -in facility
such as those located in a retail environment? Yes No . If yes, are there
any limitations? If an employee is in the medical plan and is outside of the service
area and chooses to use a walk -in facility or urgent care instead of the emergency
room, would this be covered as an in- network benefit? Yes No Are there
any limitations?
27. Can you confirm that your organization can administer all current benefits (please be
aware that MCBCC plans to opt out of Mental Health Parity requirements and follow
Florida specific Mental Health rules)? Yes No . Provide any deviations to
covered services and limitations /exclusions in TAB 3. Failure to disclose deviations
that contribute to additional claims cost may result in the Awardee(s) being
financially liable for the additional claims cost.
28. MCBCC plans to give up their Grandfathered status under HealthCare reform rules
and expects to make benefit changes. Can you accommodate benefit changes
easily? Within what time restrictions?
Section Four — Claims Administration Services Page 4
29. Provide a copy of your most recent member satisfaction survey results and indicate
the following:
a. What percentage of survey participants were very satisfied or extremely
satisfied with your plan?
b. Which aspect of your plan's performance received the lowest average
satisfaction score?
30. What fee schedule do you use for out -of- network benefits on the PPO plan? Can
you administer alternate fee schedules upon MCBCC's request? Yes No
31. What provisions are made for transition of care if a provider is terminated by your
plan? If the provider terminates the contract? Will ongoing services be treated as
in- network? Yes No For how long? Is there any additional charge, if so
what is the charge?
32. Describe, in detail, your out -of -area coverage for dependent students attending
school out of area.
33. MCBCC intends to exclude claims payment for "Never Events" in the future and
wants members to be held harmless. What is your organization's plan to address
this issue?
34. What database do you utilize to determine reasonable and customary (R &C)? What
percentile do you use to pay medical claims? How often is the database updated?
How would you advise MCBCC of the change in the database? Do you use different
R &C levels for different geographic regions?
35. For the following types of service please indicate in the chart below if you cannot
accommodate the type of payment displayed.
Provider
Type /Service
Capitation
DRG/
Case
Rates
Per
Diem
% of
Charges
Fee
Schedule
Average
Cost Per
Day or Per
Service
Adult Primary Care
Ambulatory Surgery
Centers
Chiropractic
Complex Imaging
Dermatology
Durable Medical
Equipment
Emergency Room
Section Four — Claims Administration Services Page 5
Gynecology
Hospital Based
Providers
Anesthesia
Radiology
Pathology
Emergency
Hospital Inpatient
Medical /Surgic
al
Intensive Care
Neonatal
Maternity
Hospital Outpatient
Surgical
Non - Surgical
Hospice
Obstetrics
Outpatient
Laboratory
Other Specialists
Pediatric
Podiatry
Rehabilitation
Facility
Skilled Nursing
Facility
Transplant Services
Urgent Care Center
36. Do you have a network management /provider services department that assists with
provider issues? Yes No List the staff members /titles to be assigned to
MCBCC.
37. Describe how your organization will communicate the MCBCC schedule of benefits,
changes to the schedule of benefits and general administrative policies and
procedures specific to the MCBCC Medical Plan to providers?
38. What is your average lag time for claims?
39.Are eligibility and claims administered on the same system? Yes No If no,
how are these functions integrated?
40. Will MCBCC have a dedicated team for eligibility, claims and customer service?
Yes No
Section Four — Claims Administration Services Page 6
41. Do you plan on major changes or upgrades to your administrative system or the
platform you are proposing for MCBCC in the next 24 months? Yes No . If yes,
please explain.
42. Will you provide MCBCC with an eligibility contact person for eligibility file issues and
questions? Yes No
43. What eligibility responsibilities does your organization expect MCBCC to perform?
44. Are network contracts /fee schedules loaded into your claims administration system or
must claims be submitted elsewhere for re- pricing?
45. Can your claims adjudication process block J Codes (except for neoplastic drugs from
oncologists /hematologists) from processing? How does your organization propose to
educate your network on this process?
46. Can your claims system administer pre- existing limitations? Yes No Describe.
47. What percentage of your claims submitted by facilities are filed electronically? By
physicians? Does this differ in Monroe County?
48. What percentage of your claims submitted by facilities are auto adjudicated?
%. By physicians? %
49. Provide details on the system edits that are contained in your organization's claims
processing system that assist examiners in accurately processing claims. Indicate
how your system adjusts for coding errors.
50. Describe your explanation of benefits (EOB) process. Are these are available hard
copy and /or online? Is there any flexibility? What is included on the EOB
statements?
51. Will you process run -out claims after plan termination? Yes No If yes, for
how long? At what cost?
52. Under a self funded arrangement, are you willing to accept delegation of fiduciary
responsibility with respect to claim adjudication under your ASO contract? Yes _
No
53. Can you provide an external review process to comply with recent regulatory
changes? At what cost to MCBCC?
54. Provide details regarding your organization's claims processing performance for the
most recent year for PPO plans.
Target Goal Actual
Section Four — Claims Administration Services Page 7
55. What access will MCBCC auditors have to claims and administrative data necessary
to complete an annual audit? Describe any limitations.
56. Are you willing to allow access to a full claims audit, at your expense, in the event of
significant performance issues?
a. Yes No
57. Are in and out -of- network claims paid by the same claims system? Yes
No . If two different claims systems are used, describe each and specify how
the systems interact.
58. Describe how a claims history is maintained for members who utilize both in and out -
of- network services.
59. Subrogation should be pursued in every situation where legally permissible. Please
provide information regarding your subrogation services.
Do you have a subrogation unit? Yes No
Do you subcontract with an outside firm for subrogation services? Yes No
Is there a separate cost for recovery services? Yes No
Are claims adjusters trained to screen for third party liability? Yes No
60. If you subcontract subrogation, what are the terms of your arrangement? How are
claims with subrogation potential handled and by whom? Describe how you would
provide a report to the MCBCC regarding subrogation cases and recovery.
61. Please detail your capabilities to interact with independent PBM's. Can you accept
data from them for reporting purposes? At what charge?
62. Please detail your interaction with Independent Reinsurance Carriers.
63. List all charges for claims interfacing fees for the use of an outside Stop Loss
vendor.
64. Does your plan have a 24 -hour toll free number for member services and provider
Section Four — Claims Administration Services Page 8
Performance
Clean claims processed within
10 days
% within days
% within days
Clean claims processed within
30 days
% within days
% within days
Average days turnaround
Business Days
Business Days
Coding accuracy
Financial accuracy
55. What access will MCBCC auditors have to claims and administrative data necessary
to complete an annual audit? Describe any limitations.
56. Are you willing to allow access to a full claims audit, at your expense, in the event of
significant performance issues?
a. Yes No
57. Are in and out -of- network claims paid by the same claims system? Yes
No . If two different claims systems are used, describe each and specify how
the systems interact.
58. Describe how a claims history is maintained for members who utilize both in and out -
of- network services.
59. Subrogation should be pursued in every situation where legally permissible. Please
provide information regarding your subrogation services.
Do you have a subrogation unit? Yes No
Do you subcontract with an outside firm for subrogation services? Yes No
Is there a separate cost for recovery services? Yes No
Are claims adjusters trained to screen for third party liability? Yes No
60. If you subcontract subrogation, what are the terms of your arrangement? How are
claims with subrogation potential handled and by whom? Describe how you would
provide a report to the MCBCC regarding subrogation cases and recovery.
61. Please detail your capabilities to interact with independent PBM's. Can you accept
data from them for reporting purposes? At what charge?
62. Please detail your interaction with Independent Reinsurance Carriers.
63. List all charges for claims interfacing fees for the use of an outside Stop Loss
vendor.
64. Does your plan have a 24 -hour toll free number for member services and provider
Section Four — Claims Administration Services Page 8
services? Yes No If no, what are the days and hours of operation?
65. Will Member Services /Customer Services handle all claims inquiries? If not, please
explain.
66. Will all Member Service /Customer Service Reps have access to online eligibility and
plan information?
67. Can you accommodate information from carve -out vendors for ID cards? Describe
any requirements and limitations.
68. How many cards will be distributed per family?
69. Is there a charge for replacement cards? Yes No If yes, what is the
charge?
70. What is your normal turnaround time for production and mailing of ID cards?
71. Describe your 24 -hour nurse line. Do you report on usage? Yes No
72. What are vour oraanization's taraet aoals for the followina metrics:
Member Service
Target Goal
2010 Actual
Performance
Average Speed of
Answer
Provider Directory
Average Length of Call
Links to Physicians' Websites
First Call Resolution
Rate
Call Abandonment Rate
73. Describe online resources that are available to MCBCC members:
Member Online Resources
Yes
No
Planned
Provider Directory
Links to Physicians' Websites
Claim Status
Claims History
Explanation of Benefits
Provider Performance Information (Hospital
Comparison /Profiles)
Health Risk Assessment
Personalized Health Record
Plan Policies or SPDs
Receive Personalized Health News /Information
Health Coaching
Section Four — Claims Administration Services Page 9
Ask a Nurse /Medical Questions
Disease Specific Chat Rooms
File Complaints
E -mail Member Service
Order Replacement ID Cards
Other
74. Describe your implementation process if you are the Awardee(s), including
significant deliverables, project manager and timelines, for an implementation date
of October 1, 2011. Please include how you ensure that other vendors are included
in the implementation process.
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four — Claims Administration Services Page 10
SECTION FOUR
MEDICAL MANAGEMENT
Including Prior Authorization, Utilization Review, Case Management,
and Disease Management
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Respond to the questions immediately after the question.
Organization Name:
Primary Contact/Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Submit responses in Hard Copy and Electronic Version in a useable Microsoft
Word format.
1. Can Medical Management services be purchased independent of other services?
2. If Medical Management services are purchased as stand -alone services, please
describe how you ensure coordination with other programs.
3. Are rates guaranteed for three years (36 months)?
a. Rates are requested for year 1, year 2 and year 3. On years 2 & 3, a
maximum or cap is requested.
b. Proposals submitted without maximums or cap for years 2 & 3 may not
receive the same consideration as those with a maximum or cap.
4. Explain the organization's ownership structure, listing all separate legal entities
and their relationship within the structure. Describe all major
shareholders /owners (10% or greater ownership), and list their percentage of
total ownership.
Section Four — Medical Management Page 1
5. How long has the current ownership structure been in place? Provide key dates
and brief ownership history.
6. On what date did your organization enroll its first group?
7. Please indicate each component of your Medical Management programs. If you
offer services in addition to those listed, please add additional lines and indicate
the service.
Component Yes No
Prior Authorization
Concurrent Review
Case Management
Disease Management
Indeaendent Aaaeal Process
Other:
8. Provide a copy of the appeals /denial case management process. Provide
documentation to demonstrate when /how these protocols are shared with
providers and members.
9. Is your Utilization Management (UM) service located in your claims office?
Yes No
10. If no, where is it located? How does your staff obtain access to medical
information?
11. What is the size of the UM staff in the claims office that you are proposing for
MCBCC?
12. Do you have a physician on staff to intervene on "problem" admissions or
certifications? Yes No . If not, what staff member intervenes on
problem admissions and certifications?
13. Describe the member's responsibility for compliance with UM programs, in-
network, out -of- network, and out -of -area.
14. Are your utilization review service /requirements different in any way for in-
network, out -of- network, or out -of -area participants?
15. Provide a list of services that require pre- authorization or pre- notification. Can
you accommodate changes in this listing if requested by the client?
Section Four — Medical Management Page 2
16. Describe how pre- authorization or pre- notification interfaces with claims
adjudication (particularly if you are not the selected as the claims administrator).
17. Do providers have access to your coverage positions or clinical guidelines?
How?
18. Do members have access to your coverage positions or clinical guidelines?
How?
19. Are network providers at risk for not following your Medical Management
Program? Yes No . Please explain.
20. Are members at risk if a network provider does not follow your Medical
Management Program (i.e. is there any financial responsibility for the member in
excess of the stated coinsurance /copayment)?
21. Describe your pre- certification process for inpatient admissions.
22. Describe how inpatient utilization is managed. Specifically address after hours,
emergency, in and out -of- network admissions.
23. Describe your procedures for concurrent review.
24. Is inpatient census reviewed on a daily basis? Yes No If no, how
often?
25. How do you communicate with patients and family members regarding length of
stay and discharge planning?
26. Describe your Case Management Program.
27. How are members identified for enrollment in Case Management?
28. Are there any cases the Case Management Program will not manage?
Yes No . If yes, describe.
29. Do members in Case Management have a consistent Nurse Manager presiding
over each case? Yes No
30. How is clinical progress communicated to patients and physicians?
31. How are members discharged from Case Management? Are members
introduced to the Disease Management program by Case Managers, if
necessary?
32. Describe how providers and members are made aware of Case Management.
33. Do you report your Case Management results? Yes No . If yes, include
samples.
Section Four — Medical Management Page 3
34. What are the readmission rates for participants in your UR /Case Management
programs (within 30 days of discharge) for South Florida? For Monroe County?
35. What are the minimum qualifications for Clinical Case Managers and Utilization
Management staff?
36. Are your Disease Management Programs accredited? Yes No If yes,
by which accreditation organization and status achieved?
37. Provide details on how your Disease Management Programs remain current
based on research and industry trends.
38. Please indicate the Disease Management programs you currently offer. If you
currently offer services in addition to those listed, please add additional lines and
indicate the service.
Component Yes No
Asthma
Cancer
Lower Back Pain
Chronic Kidney Disease
Congestive Heart Failure
Diabetes
Coronary Artery Disease
End Stage Renal Disease
COPD
Hypertension
HIV
Depression
Arthritis
Hiah Risk Obstetrics
Other:
39. What additional Disease Management Programs are planned for the next two (2)
years?
40. Describe your 24 -hour nurse line. Do you report on usage? Yes No
41. Are network providers made aware of the availability of your Disease
Management Program? How?
42. What criteria are used to identify and select members for participation in each of
the Disease Management Programs?
43. Are members identified for Disease Management automatically enrolled
Section Four — Medical Management Page 4
(requiring them to opt -out if they choose not to participate) or do members
identified for Disease Management have to enroll to participate?
44. What are your organization's criteria to discharge /disenroll a member from
Disease Management?
45. Provide patient attrition rate (patient disenrollment without completing the
program) in 2009 and 2010 for each Disease Management Program offered.
46. Describe the type and number of staff professionals (PA's, LPN's, RN's and
Nurse Practitioners) who will be handling MCBCC members. How is the staff
assigned to each case? Describe oversight /supervision by physicians.
47. Are patients' physicians notified of the patient's progress, or lack of progress, in
the Disease Management care plan?
48. All members in the Disease Management Program should have a specific nurse
manager regardless of whether they are suffering from one or more than one
chronic condition. If there are exceptions, explain each.
49. How does your organization measure clinical impact of each Disease
Management Program? Please provide an example of your report for the 2010
calendar year versus the 2009 calendar year.
50. Do you accept medical claims data for any aspect of Disease Management
applications? If so, please outline your data transfer protocols, timing, and list
applicable charges in Section Five — Pricing Exhibits.
51. Do you accept prescription drug data for any aspect of Disease Management
applications? If so, please outline your data transfer protocols, timing, and list
applicable charges in Section Five — Pricing Exhibits.
52. Do you seek laboratory and /or x -ray results for any aspect of Disease
Management applications? If so, please outline how you obtain the information
and how it is used.
53. Do you interface with Wellness programs or Wellness vendors? If so, please
describe how you interact.
54. Do you provide Wellness vendors with Medical Management information?
Please elaborate. If there is an additional charge for this interface please list
applicable charges in the Pricing exhibit.
55. Describe your medical protocols to determine:
A. Medical necessity
B. Medical appropriateness
Section Four — Medical Management Page 5
C. Experimental and investigational treatment
56. Describe your Quality Assurance program.
57. Provide specific examples as to how your objective measurement and information
sharing process has improved clinical and financial outcomes in South Florida
over the past two years.
58. How can you assist MCBCC with targeted comprehensive initiatives to improve
the health of the MCBCC population? Can you report on the effectiveness of
implemented initiatives, including clinical feedback to providers and follow -up
activities when indicated? Please provide samples.
59. Describe the process to share information with providers, facilities and hospitals.
60. What is the typical ROI achieved on your Disease Management programs? How
long would MCBCC expect to wait to achieve these results?
61. List the total employer groups and total members your company provided
Disease Management Programs to as of December 31, 2009 and December 31,
2010. Complete the table below:
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four — Medical Management Page 6
As of December 31, 2009
As of December 31, 2010
Employer
Members
Employer
Members
Groups
Groups
Nationally
Florida
South Florida
(Monroe
County, Miami
Dade County)
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four — Medical Management Page 6
SECTION FOUR
PPO NETWORK AND NETWORK MANAGEMENT
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Respond to the questions immediately after the question.
Organization Name:
Primary Contact /Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Submit responses in Hard Copy and Electronic Version in a useable Microsoft
Word format.
1. Can PPO network services be purchased independent of other services?
2. Are rates guaranteed for three years (36 months)?
a. Rates are requested for year 1, year 2 and year 3. On years 2 & 3, a
maximum or cap is requested.
b. Proposals submitted without maximums or cap for years 2 & 3 may not
receive the same consideration as those with a maximum or cap.
3. Explain the organization's ownership structure, listing all separate legal entities
and their relationship within the structure. Describe all major
shareholders /owners (10% or greater ownership), and list their percentage of
total ownership.
4. How long has the current ownership structure been in place? Provide key dates
and brief ownership history.
5. What date did your organization enroll its first group?
6. List all cities in Florida with populations in excess of 25,000 where your
Section Four — PPO Network and Network Management Page 1
organization (or parent company) has no PPO network availability. List all cities
in other states in the U.S. with populations in excess of 50,000 where your
organization (or parent company) has no PPO network availability.
7. Please provide data requested below for PPO plan participants.
Total participants
Gross disenrollment*
2010
Number
2011
Number
*Gross disenrollment is the total number of eligible network participants on January 1,
2010 who were no longer participants on January 1, 2011. Express gross disenrollment
as a percent of total enrollment at January 1, 2010.
8. Have you changed the size or structure of either the primary care or specialty
care network for Monroe or Miami -Dade Counties during the past 12 months?
Yes No . If yes, explain.
9. Complete the following GeoAccess summary for MCBCC participants. The
description of the census file layout is included in Attachment D. Your study
should include a summary report for each of the items listed below. Each
summary should indicate the overall number and percentage of employees with
access by zip code for all networks that you are proposing. Please include
GeoAccess Reports.
a. Number and percentage of employees with two (2) adult Primary Care
Physicians (Family Practice, General Practice, Internists) within 10 miles
of the employee's zip code.
b. Number and percentage of employees with two (2) Pediatricians within 10
miles of the employee's zip code.
c. Number and percentage of employees with two OB /GYNs within 10 miles
of the employee's zip code.
d. Number and percentage of employees with two (2) Specialists within 12
miles of the employee's zip code.
e. Number and percentage of employees with access to 1 hospital within 20
miles of the zip code
Section Four — PPO Network and Network Management Page 2
Adult
Pediatricians
OB /GYN
Specialists
Hospitals
PCP's
2 in 10 miles
2 in 10
2 in 12
1 in 20
2 in 10
miles
miles
miles
miles
Number
meeting
standard
% meeting
Section Four — PPO Network and Network Management Page 2
standard
10. Complete the following GeoAccess summary for MCBCC participants using the
same access standards as above. Please list the number of participants in
the top 10 CITIES that do not meet the access standards.
List City
and
number
without
access
Adult
PCP's
2 in 10
miles
Pediatricians
2 in 10 miles
OB /GYN
2 in 10
miles
Specialists
2 in 12
miles
Hospitals
1 in 20
miles
Example
Marathon - 5
Key West - 3
Key Largo - 1
Ke West - 1
None
1
2
Fisherman's
Hospital
2
3
Mariners'
Hospital
3
4
5
6
11. Please indicate your contract status for the listed hospital providers in Monroe
County. Please provide your contract status for your top ten physician /physician
group providers (by number of encounters) in Monroe County. Provide the
current contract status and the contract's expiration date.
Monroe County
Monroe County Hospitals Top Ten Physicians /Physician groups
Section Four — PPO Network and Network Management Page 3
Hospital
Contract
Status
Contract
Expiration
Date
Date of
Last
Contract
Change
Physicians/
Physician
Group
Contract
Status
Contract
Expiration
Date
Date of
Last
Contract
Change
1
Lower Keys
Hospital
1
2
Fisherman's
Hospital
2
3
Mariners'
Hospital
3
4
5
6
7
8
9
10
Section Four — PPO Network and Network Management Page 3
12. Please indicate your contract status for your top hospital providers in Miami -Dade
County, (by number of admissions) as well as your top ten physician /physician group
providers (by number of encounters) in Miami -Dade County. Indicate the current
contract status and the contract's expiration date.
Miami -Dade Miami -Dade
Top Ten Hospitals Top Ten Physicians /Physician groups
13. Please provide a CD, computer tape, or other electronic media, in a useable Excel
format, containing a list of all your Monroe County and Miami -Dade County
contracted PPO providers. The format required is one line per record (each
provider is one record), with each component piece of data laid out in
separate columns to the right (i.e. last name, first name, tax ID, address 1,
address 2, city, state, zip, specialty):
a. Physicians:
i.Full name (Last, First)
ii.Tax ID
iii.Full address (if practices are in more than one location, list all locations
and tax ID)
iv.Specialty
b. Hospitals
i.Full name
ii.Tax ID
iii.Full address
iv.Level of service (primary, secondary, tertiary)
14. Have there been any changes to your South Florida (Monroe or Miami -Dade
Counties) hospital network in 2008, 2009, or 2010? Yes No
15. List what steps your organization will take to ensure that the proposed hospital
network remains stable within the South Florida (Monroe, Miami -Dade) area.
Section Four — PPO Network and Network Management Page 4
Hospital
Contract
Status
Contract
Expiration
Date
Date of
Last
Contract
Change
Physicians/
Physician
Group
Contract
Status
Contract
Expiratio
n Date
Date of
Last
Contract
Change
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
13. Please provide a CD, computer tape, or other electronic media, in a useable Excel
format, containing a list of all your Monroe County and Miami -Dade County
contracted PPO providers. The format required is one line per record (each
provider is one record), with each component piece of data laid out in
separate columns to the right (i.e. last name, first name, tax ID, address 1,
address 2, city, state, zip, specialty):
a. Physicians:
i.Full name (Last, First)
ii.Tax ID
iii.Full address (if practices are in more than one location, list all locations
and tax ID)
iv.Specialty
b. Hospitals
i.Full name
ii.Tax ID
iii.Full address
iv.Level of service (primary, secondary, tertiary)
14. Have there been any changes to your South Florida (Monroe or Miami -Dade
Counties) hospital network in 2008, 2009, or 2010? Yes No
15. List what steps your organization will take to ensure that the proposed hospital
network remains stable within the South Florida (Monroe, Miami -Dade) area.
Section Four — PPO Network and Network Management Page 4
16. Are there any hospitals in the Monroe County and Miami -Dade County area with
which you are not contracted? Yes No . If yes, list all hospitals.
17. Complete the following exhibits for Monroe and Miami -Dade Counties.
County
Number of
Number of
Number of Mental
Number of
Percentage of
Number of
PCPs
Specialty
Health /Substance
Mental Health
Physicians Board
Independent
Home Health
Physicians
Abuse Facilities
Professionals
Certified or
Radiology
Lab Facilities
Care
(Designate
(Designate
Board - eligible
Tertiary
Centers
inpatient or
separately:
Convenient Care
Care
outpatient
Psychiatrist
Centers
numbers
Psychologist
separately)
separately)
LCSW)
Monroe
Monroe
Miami -Dade
Miami -Dade
County
Number of
Number of Urgent
Number of
Number of
Number of
Number of
Acute Care
Care Facilities
Hospitals
Independent
Independent
Home Health
Hospitals
(Designate Urgent
Offering
Radiology
Lab Facilities
Care
Care facilities and
Tertiary
Centers
Agencies
Convenient Care
Care
Centers
separately)
Monroe
Miami -Dade
18. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and
radiology) affiliated with network hospitals contracted? Yes No If no, list
any hospital physician group(s) without contracts and the hospital they service.
19. If your contracted network of providers extends outside of the target areas
(Monroe and Miami -Dade Counties), please describe the geographical
boundaries (i.e., Florida, National, etc.) where MCBCC members will have
access through the contracted network. Please describe any authorization
requirements for covered services (non- urgent or emergency services) received
outside the target areas. Please describe any authorization requirements for
covered services (non- urgent or emergency services) received outside of the
State of Florida, both within and outside the United States.
20. Describe the specific measures used by your organization to monitor physician
access in the area in which your network operates. Provide the most recent
corresponding statistics available. (Examples: physician -to- member ratios,
average wait time required for an appointment, etc.)
21. How and when do you audit your network to determine if the access standards
Section Four — PPO Network and Network Management Page 5
are met? Provide a copy of your most recent report.
22. What percentage of your network physicians offer expanded office hours? How
is this information communicated to members?
23. Are PCP and Specialist contracts evergreen? Yes No . If no, what are
the termination requirements within your provider contracts as far as timeframes
and notification?
24. Describe, in detail, your out -of -area coverage for dependent students attending
school out of area.
25. Do you have a network in the following areas where MCBCC has a high
concentration of college dependents?
Daytona Beach
❑ Yes
❑ No
Gainesville, Florida
❑ Yes
❑ No
Tallahassee, Florida
❑ Yes
❑ No
Orlando, Florida
❑ Yes
❑ No
Tampa, Florida
❑ Yes
❑ No
26. What is your overall network pricing as compared to prevailing Medicare
reimbursement in Monroe County for hospitals? For physicians? Please provide
the same information for Miami -Dade County.
27. Do any network contracts include outlier provisions? Yes No If yes,
explain.
28. Are changes to your network pricing planned for 2011, and 2012?
29. MCBCC intends to exclude claims payment for "Never Events" in the future and
wants members to be held harmless. What is your organization's recontracting
plan to address this issue?
30. What database do you utilize to determine reasonable and customary (R &C)?
What percentile do you use to pay medical claims? How often is the database
updated? Do you use different R &C levels for different products?
31. Provide hospital cost data for Monroe County Only
Section Four — PPO Network and Network Management Page 6
2008
2009
2010
PPO
PPO
PPO
Average cost per
admission
Average cost per day
Section Four — PPO Network and Network Management Page 6
Average discount level
Average length of stay
Days per 1000
Admissions per 1000
Provide hospital cost data for Miami -Dade County Only
32. Hospital Pricing Analysis for Monroe and Miami -Dade Counties Only
Complete the following tables for hospital inpatient and hospital outpatient
services.
Hospital Inpatient
Type of
2008
2009
2010
Average Eligible
PPO
PPO
PPO
Average cost per
admission
% of Days
Charge Per Day
Per Diem
Average cost per day
Miami-
Miami-
Average discount level
Miami-
Miami-
Average length of stay
Miami -
Dade Monroe
Dade
Days per 1000
Dade
Monroe
Dade
Admissions per 1000
Dade
Monroe
Dade
32. Hospital Pricing Analysis for Monroe and Miami -Dade Counties Only
Complete the following tables for hospital inpatient and hospital outpatient
services.
Hospital Inpatient
Type of
Sub-
Average Allowed
Average Eligible
Average Negotiated
Admission
Category
% of Admissions
% of Days
Charge Per Day
Per Diem
Miami-
Miami-
Miami-
Miami-
Miami -
Dade Monroe
Dade
Monroe
Dade
Monroe
Dade
Monroe
Dade
Monroe
Dade
Medical/
$
%
%
Surgical
%
%
%
%
$
$
$
$
ICU /CCU
Adult
%
%
%
%
$
$
$
$
Pediatric
$
$
$
$
Neonatal
%
%
%
%
Maternity
Vaginal
%
%
%
%
$
$
$
$
C- Section
%
%
%
%
$
$
$
$
Cardiac
$
$
$
$
Surgery
%
%
%
%
Total
Note: Eligible charges are submitted charges less ineligible charges such as
duplicates, non - covered items, etc. Average Negotiated Per Diem should include
the impact of any outlier provisions.
Hospital Outpatient
Section Four — PPO Network and Network Management Page 7
Average Allowed
Reimbursement Average Eligible Charge
Amount Per
Net Effective
Type of Service
Method Per Encounter
Encounter
Discount %
Miami-
Miami-
Miami-
Miami -
Monroe
Dade Monroe
Dade
Monroe
Dade
Monroe
Dade
Surgery
I $
$
$
$
%
%
Section Four — PPO Network and Network Management Page 7
Emergency Room
❑ Yes ❑
Facility(ies):
$
$
$
$
%
%
Radiology
No
$
$
$
$
%
%
Pathology
❑ Yes ❑
Facility(ies):
$
$
$
$
%
%
Therapy (PT /OT /ST)
No
$
$
$
$
%
%
Other
$
$
$
$
%
%
Total
Note: Reimbursement Method refers to case rates, flat fees, % of Medicare,
Allowable, % Discount, etc.
33. Proposer must complete Attachment H "Medical Pricing Form" in full. The rates
should be based on average reimbursements for Monroe County and Miami -
Dade providers, NOT statewide provider averages. Use reimbursement rates as
of January 1, 2011.
34. Proposer may be requested to complete a Medical Claims Repricing Worksheet
in full at a later time. Will you be able to comply to such a request within 2 weeks
of the request? Yes No
35. Have you changed affiliations for ancillary services (diagnostic services,
prescription drug benefits, etc.) in Miami -Dade or Palm Beach Counties during
the past 12 months? Yes No . If yes, describe such changes.
36. If your network has capitated charges (i.e., behavioral health, labs, chiropractic,
etc.) built into your premium rates (fully- insured) or claim and expenses charges
(self- funded), disclose all such charges, fees and detail what they cover, and the
amount of the charge for each.
37. Indicate if you have a "Centers of Excellence" program for each of the following
and list your designated facilities for each:
Transplants
❑ Yes ❑
Facility(ies):
No
Cardiovascular
❑ Yes ❑
Facility(ies):
No
Cancer
❑ Yes ❑
Facility(ies):
No
HIV /AIDS
❑ Yes ❑
Facility(ies):
No
Neonatal
❑ Yes ❑
Facility(ies):
No
38. Describe your organization's policies regarding your "Centers of Excellence"
program. Is the program voluntary or mandatory?
Voluntary Mandatory
39. Please describe any discount arrangements with hospitals or other providers
Section Four — PPO Network and Network Management Page 8
outside your normal network that you define as a "center of excellence."
40. Does your mental health /substance abuse network interface with employer
EAPs? If yes, please describe.
41. Will you carve out your mental health /substance abuse services?
42. Is your network currently contracting with any disease management provider
groups? If yes, please describe in detail. If no, please describe any plans for
doing so in the future.
43. Will you coordinate /cooperate with outside disease management vendors?
44. Describe how your organization will communicate the MCBCC schedule of
benefits, changes to the schedule of benefits and general administrative policies
and procedures specific to the MCBCC Medical Plan to providers?
45. Describe how your organization will ensure that providers in your network refer to
network facilities and other network providers?
46. List the hospital selection /evaluation criteria you use. Specify the
certifications /credentials you contractually require hospitals to maintain (e.g.,
licensure, JCAHO accreditation, evidence of liability insurance, etc.). You may
add additional lines as needed.
Contractually Verified
Maintained Annually
Criteria (Yes or No) (Yes or
No)
1.
2.
3.
4.
47. Which of the following healthcare services are not available within the target area
network (Monroe and Miami -Dade County)? What arrangements have been
made to provide these services?
Section Four — PPO Network and Network Management Page 9
a. Alcoholism /chemical dependency (inpatient and outpatient)
b. Ambulatory surgery
c. Cardiac catheterization laboratory
d. CT scanner
e. Emergency department
f. Intensive care unit
g. Neonatal intensive care unit
h. Obstetrics
i. Open heart surgery
j. Pediatric inpatient unit
k. Psychiatric (inpatient and outpatient)
I. X -ray radiation therapy
48. Please indicate if your organization's physician application and credentialing
process requires the following:
a. Written verification of education and experience
b. Verification of current license and DEA certificate
c. Investigation for adverse action on license and /or hospital
privileges
d. Verification of letters of recommendation
e. On -site inspection of physician offices
f. Personal interviews
g. Check malpractice history with appropriate state /federal
agencies
h. Malpractice insurance includes limits of at least $1 million per
occurrence and $3 million aggregate
i. Regular recertification of participating physicians
49. Is the credentialing function delegated? If yes, to whom?
• Hospital
• IPA
• Other (please specify):
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
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❑ Yes ❑ No
50. Does your organization selectively drop physicians within a medical
group /physician association while continuing to contract with the medical
group /physician association?
51. What was your physician turnover in the past year?
• Family practice physicians, internists, pediatricians, Ob /Gyns
• Other Specialists
52. How often do you visit physicians on -site to explain contracts and contract
changes?
Section Four — PPO Network and Network Management Page 10
53. Do credentialing policies and procedures meet accreditation standards? Yes
No If yes, what accreditation organization?
54. Do you accept client requests to approach specific providers?
55. How long does it take to credential a new physician?
56. Is there a formal committee that sets participating provider quality assurance
policy and reviews treatment outcomes on a regular basis? If so, who is on the
committee and how often does it meet?
57. Describe how quality assurance activities are used to recredential, recontract,
and /or evaluate individual provider performance.
58. Describe how quality assurance activities are used to monitor complaints and
used to improve patient care and service.
59. Describe any education programs for staff.
60. Do you issue separate reports to providers to help them measure their practices
in terms of practice patterns /variations and costs of alternative
treatments /procedures? If so, provide samples.
61. Describe the responsibilities, credentials, and reporting relationships of the
people who work in the quality assurance program.
62. How are disputes or questions handled about reimbursement amounts:
a. Between a patient and the provider?
b. Between the claim payor and the provider?
63. Between recredentialing cycles, do you conduct ongoing monitoring of
practitioner sanctions, complaints and quality issues? Yes No If yes,
how often?
64. Do you perform patient satisfaction surveys? If so, describe and provide
samples and results.
65. Please describe your procedure for evaluating a provider's performance.
66. Describe your criteria for dismissing or dropping a participating physician or
hospital.
67. How many providers have been disciplined or dropped over the past three years
from your network? Please provide the number of physicians terminated in
Monroe County and Miami -Dade County (separately) who failed to maintain
credentialing standards and the number who have been terminated due to quality
Section Four — PPO Network and Network Management Page 11
assurance reasons.
68. Describe the services and features members have access to on your website.
Please provide the URL for your website.
69. Describe your 24 -hour nurse line. Do you report on usage? Yes No
70. Do you process and reprice network claims before they are submitted to the
claim payor? Please describe this process in detail.
71. What fee schedule do you use for out -of- network benefits on the PPO plan? Can
you administer alternate fee schedules upon MCBCC's request?
Yes No
72. What is your target turnaround time for repricing? What is your average actual
turnaround time over the past two years?
73. Can the claim payors' system automatically determine reimbursement for
participating providers?
74.Are there specific third party administrators or claim payment systems you are
unable to work with? Provide a list of third party administrators who are currently
pricing claims for your mutual clients.
75. Will you accept eligibility data in electronic format? If yes, please specify
acceptable formats.
76. Describe in detail your procedure to communicate network changes to the TPA,
employer client, employees.
77. Do you provide hard copy network directories for distribution? If so, at what
cost? Will you provide a PDF file or camera -ready material for MCBCC to
produce and distribute directories?
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four — PPO Network and Network Management Page 12
SECTION FOUR
PPO NETWORK AND NETWORK MANAGEMENT
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Respond to the questions immediately after the question.
Organization Name:
Primary Contact /Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Submit responses in Hard Copy and Electronic Version in a useable Microsoft
Word format.
1. Can PPO network services be purchased independent of other services?
2. Are rates guaranteed for three years (36 months)?
a. Rates are requested for year 1, year 2 and year 3. On years 2 & 3, a
maximum or cap is requested.
b. Proposals submitted without maximums or cap for years 2 & 3 may not
receive the same consideration as those with a maximum or cap.
3. Explain the organization's ownership structure, listing all separate legal entities
and their relationship within the structure. Describe all major
shareholders /owners (10% or greater ownership), and list their percentage of
total ownership.
4. How long has the current ownership structure been in place? Provide key dates
and brief ownership history.
5. What date did your organization enroll its first group?
6. List all cities in Florida with populations in excess of 25,000 where your
Section Four — PPO Network and Network Management Page 1
organization (or parent company) has no PPO network availability. List all cities
in other states in the U.S. with populations in excess of 50,000 where your
organization (or parent company) has no PPO network availability.
7. Please provide data requested below for PPO plan participants.
Total participants
Gross disenrollment*
2010
Number
2011
Number
*Gross disenrollment is the total number of eligible network participants on January 1,
2010 who were no longer participants on January 1, 2011. Express gross disenrollment
as a percent of total enrollment at January 1, 2010.
8. Have you changed the size or structure of either the primary care or specialty
care network for Monroe or Miami -Dade Counties during the past 12 months?
Yes No . If yes, explain.
9. Complete the following GeoAccess summary for MCBCC participants. The
description of the census file layout is included in Attachment D. Your study
should include a summary report for each of the items listed below. Each
summary should indicate the overall number and percentage of employees with
access by zip code for all networks that you are proposing. Please include
GeoAccess Reports.
a. Number and percentage of employees with two (2) adult Primary Care
Physicians (Family Practice, General Practice, Internists) within 10 miles
of the employee's zip code.
b. Number and percentage of employees with two (2) Pediatricians within 10
miles of the employee's zip code.
c. Number and percentage of employees with two OB /GYNs within 10 miles
of the employee's zip code.
d. Number and percentage of employees with two (2) Specialists within 12
miles of the employee's zip code.
e. Number and percentage of employees with access to 1 hospital within 20
miles of the zip code
Section Four — PPO Network and Network Management Page 2
Adult
Pediatricians
OB /GYN
Specialists
Hospitals
PCP's
2 in 10 miles
2 in 10
2 in 12
1 in 20
2 in 10
miles
miles
miles
miles
Number
meeting
standard
% meeting
Section Four — PPO Network and Network Management Page 2
standard
10. Complete the following GeoAccess summary for MCBCC participants using the
same access standards as above. Please list the number of participants in
the top 10 CITIES that do not meet the access standards.
List City
and
number
without
access
Adult
PCP's
2 in 10
miles
Pediatricians
2 in 10 miles
OB /GYN
2 in 10
miles
Specialists
2 in 12
miles
Hospitals
1 in 20
miles
Example
Marathon - 5
Key West - 3
Key Largo - 1
Ke West - 1
None
1
2
Fisherman's
Hospital
2
3
Mariners'
Hospital
3
4
5
6
11. Please indicate your contract status for the listed hospital providers in Monroe
County. Please provide your contract status for your top ten physician /physician
group providers (by number of encounters) in Monroe County. Provide the
current contract status and the contract's expiration date.
Monroe County
Monroe County Hospitals Top Ten Physicians /Physician groups
Section Four — PPO Network and Network Management Page 3
Hospital
Contract
Status
Contract
Expiration
Date
Date of
Last
Contract
Change
Physicians/
Physician
Group
Contract
Status
Contract
Expiration
Date
Date of
Last
Contract
Change
1
Lower Keys
Hospital
1
2
Fisherman's
Hospital
2
3
Mariners'
Hospital
3
4
5
6
7
8
9
10
Section Four — PPO Network and Network Management Page 3
12. Please indicate your contract status for your top hospital providers in Miami -Dade
County, (by number of admissions) as well as your top ten physician /physician group
providers (by number of encounters) in Miami -Dade County. Indicate the current
contract status and the contract's expiration date.
Miami -Dade Miami -Dade
Top Ten Hospitals Top Ten Physicians /Physician groups
13. Please provide a CD, computer tape, or other electronic media, in a useable Excel
format, containing a list of all your Monroe County and Miami -Dade County
contracted PPO providers. The format required is one line per record (each
provider is one record), with each component piece of data laid out in
separate columns to the right (i.e. last name, first name, tax ID, address 1,
address 2, city, state, zip, specialty):
a. Physicians:
i.Full name (Last, First)
ii.Tax ID
iii.Full address (if practices are in more than one location, list all locations
and tax ID)
iv.Specialty
b. Hospitals
i.Full name
ii.Tax ID
iii.Full address
iv.Level of service (primary, secondary, tertiary)
14. Have there been any changes to your South Florida (Monroe or Miami -Dade
Counties) hospital network in 2008, 2009, or 2010? Yes No
15. List what steps your organization will take to ensure that the proposed hospital
network remains stable within the South Florida (Monroe, Miami -Dade) area.
Section Four — PPO Network and Network Management Page 4
Hospital
Contract
Status
Contract
Expiration
Date
Date of
Last
Contract
Change
Physicians/
Physician
Group
Contract
Status
Contract
Expiratio
n Date
Date of
Last
Contract
Change
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
13. Please provide a CD, computer tape, or other electronic media, in a useable Excel
format, containing a list of all your Monroe County and Miami -Dade County
contracted PPO providers. The format required is one line per record (each
provider is one record), with each component piece of data laid out in
separate columns to the right (i.e. last name, first name, tax ID, address 1,
address 2, city, state, zip, specialty):
a. Physicians:
i.Full name (Last, First)
ii.Tax ID
iii.Full address (if practices are in more than one location, list all locations
and tax ID)
iv.Specialty
b. Hospitals
i.Full name
ii.Tax ID
iii.Full address
iv.Level of service (primary, secondary, tertiary)
14. Have there been any changes to your South Florida (Monroe or Miami -Dade
Counties) hospital network in 2008, 2009, or 2010? Yes No
15. List what steps your organization will take to ensure that the proposed hospital
network remains stable within the South Florida (Monroe, Miami -Dade) area.
Section Four — PPO Network and Network Management Page 4
16. Are there any hospitals in the Monroe County and Miami -Dade County area with
which you are not contracted? Yes No . If yes, list all hospitals.
17. Complete the following exhibits for Monroe and Miami -Dade Counties.
County
Number of
Number of
Number of Mental
Number of
Percentage of
Number of
PCPs
Specialty
Health /Substance
Mental Health
Physicians Board
Independent
Home Health
Physicians
Abuse Facilities
Professionals
Certified or
Radiology
Lab Facilities
Care
(Designate
(Designate
Board - eligible
Tertiary
Centers
inpatient or
separately:
Convenient Care
Care
outpatient
Psychiatrist
Centers
numbers
Psychologist
separately)
separately)
LCSW)
Monroe
Monroe
Miami -Dade
Miami -Dade
County
Number of
Number of Urgent
Number of
Number of
Number of
Number of
Acute Care
Care Facilities
Hospitals
Independent
Independent
Home Health
Hospitals
(Designate Urgent
Offering
Radiology
Lab Facilities
Care
Care facilities and
Tertiary
Centers
Agencies
Convenient Care
Care
Centers
separately)
Monroe
Miami -Dade
18. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and
radiology) affiliated with network hospitals contracted? Yes No If no, list
any hospital physician group(s) without contracts and the hospital they service.
19. If your contracted network of providers extends outside of the target areas
(Monroe and Miami -Dade Counties), please describe the geographical
boundaries (i.e., Florida, National, etc.) where MCBCC members will have
access through the contracted network. Please describe any authorization
requirements for covered services (non- urgent or emergency services) received
outside the target areas. Please describe any authorization requirements for
covered services (non- urgent or emergency services) received outside of the
State of Florida, both within and outside the United States.
20. Describe the specific measures used by your organization to monitor physician
access in the area in which your network operates. Provide the most recent
corresponding statistics available. (Examples: physician -to- member ratios,
average wait time required for an appointment, etc.)
21. How and when do you audit your network to determine if the access standards
Section Four — PPO Network and Network Management Page 5
are met? Provide a copy of your most recent report.
22. What percentage of your network physicians offer expanded office hours? How
is this information communicated to members?
23. Are PCP and Specialist contracts evergreen? Yes No . If no, what are
the termination requirements within your provider contracts as far as timeframes
and notification?
24. Describe, in detail, your out -of -area coverage for dependent students attending
school out of area.
25. Do you have a network in the following areas where MCBCC has a high
concentration of college dependents?
Daytona Beach
❑ Yes
❑ No
Gainesville, Florida
❑ Yes
❑ No
Tallahassee, Florida
❑ Yes
❑ No
Orlando, Florida
❑ Yes
❑ No
Tampa, Florida
❑ Yes
❑ No
26. What is your overall network pricing as compared to prevailing Medicare
reimbursement in Monroe County for hospitals? For physicians? Please provide
the same information for Miami -Dade County.
27. Do any network contracts include outlier provisions? Yes No If yes,
explain.
28. Are changes to your network pricing planned for 2011, and 2012?
29. MCBCC intends to exclude claims payment for "Never Events" in the future and
wants members to be held harmless. What is your organization's recontracting
plan to address this issue?
30. What database do you utilize to determine reasonable and customary (R &C)?
What percentile do you use to pay medical claims? How often is the database
updated? Do you use different R &C levels for different products?
31. Provide hospital cost data for Monroe County Only
Section Four — PPO Network and Network Management Page 6
2008
2009
2010
PPO
PPO
PPO
Average cost per
admission
Average cost per day
Section Four — PPO Network and Network Management Page 6
Average discount level
Average length of stay
Days per 1000
Admissions per 1000
Provide hospital cost data for Miami -Dade County Only
32. Hospital Pricing Analysis for Monroe and Miami -Dade Counties Only
Complete the following tables for hospital inpatient and hospital outpatient
services.
Hospital Inpatient
Type of
2008
2009
2010
Average Eligible
PPO
PPO
PPO
Average cost per
admission
% of Days
Charge Per Day
Per Diem
Average cost per day
Miami-
Miami-
Average discount level
Miami-
Miami-
Average length of stay
Miami -
Dade Monroe
Dade
Days per 1000
Dade
Monroe
Dade
Admissions per 1000
Dade
Monroe
Dade
32. Hospital Pricing Analysis for Monroe and Miami -Dade Counties Only
Complete the following tables for hospital inpatient and hospital outpatient
services.
Hospital Inpatient
Type of
Sub-
Average Allowed
Average Eligible
Average Negotiated
Admission
Category
% of Admissions
% of Days
Charge Per Day
Per Diem
Miami-
Miami-
Miami-
Miami-
Miami -
Dade Monroe
Dade
Monroe
Dade
Monroe
Dade
Monroe
Dade
Monroe
Dade
Medical/
$
%
%
Surgical
%
%
%
%
$
$
$
$
ICU /CCU
Adult
%
%
%
%
$
$
$
$
Pediatric
$
$
$
$
Neonatal
%
%
%
%
Maternity
Vaginal
%
%
%
%
$
$
$
$
C- Section
%
%
%
%
$
$
$
$
Cardiac
$
$
$
$
Surgery
%
%
%
%
Total
Note: Eligible charges are submitted charges less ineligible charges such as
duplicates, non - covered items, etc. Average Negotiated Per Diem should include
the impact of any outlier provisions.
Hospital Outpatient
Section Four — PPO Network and Network Management Page 7
Average Allowed
Reimbursement Average Eligible Charge
Amount Per
Net Effective
Type of Service
Method Per Encounter
Encounter
Discount %
Miami-
Miami-
Miami-
Miami -
Monroe
Dade Monroe
Dade
Monroe
Dade
Monroe
Dade
Surgery
I $
$
$
$
%
%
Section Four — PPO Network and Network Management Page 7
Emergency Room
❑ Yes ❑
Facility(ies):
$
$
$
$
%
%
Radiology
No
$
$
$
$
%
%
Pathology
❑ Yes ❑
Facility(ies):
$
$
$
$
%
%
Therapy (PT /OT /ST)
No
$
$
$
$
%
%
Other
$
$
$
$
%
%
Total
Note: Reimbursement Method refers to case rates, flat fees, % of Medicare,
Allowable, % Discount, etc.
33. Proposer must complete Attachment H "Medical Pricing Form" in full. The rates
should be based on average reimbursements for Monroe County and Miami -
Dade providers, NOT statewide provider averages. Use reimbursement rates as
of January 1, 2011.
34. Proposer may be requested to complete a Medical Claims Repricing Worksheet
in full at a later time. Will you be able to comply to such a request within 2 weeks
of the request? Yes No
35. Have you changed affiliations for ancillary services (diagnostic services,
prescription drug benefits, etc.) in Miami -Dade or Palm Beach Counties during
the past 12 months? Yes No . If yes, describe such changes.
36. If your network has capitated charges (i.e., behavioral health, labs, chiropractic,
etc.) built into your premium rates (fully- insured) or claim and expenses charges
(self- funded), disclose all such charges, fees and detail what they cover, and the
amount of the charge for each.
37. Indicate if you have a "Centers of Excellence" program for each of the following
and list your designated facilities for each:
Transplants
❑ Yes ❑
Facility(ies):
No
Cardiovascular
❑ Yes ❑
Facility(ies):
No
Cancer
❑ Yes ❑
Facility(ies):
No
HIV /AIDS
❑ Yes ❑
Facility(ies):
No
Neonatal
❑ Yes ❑
Facility(ies):
No
38. Describe your organization's policies regarding your "Centers of Excellence"
program. Is the program voluntary or mandatory?
Voluntary Mandatory
39. Please describe any discount arrangements with hospitals or other providers
Section Four — PPO Network and Network Management Page 8
outside your normal network that you define as a "center of excellence."
40. Does your mental health /substance abuse network interface with employer
EAPs? If yes, please describe.
41. Will you carve out your mental health /substance abuse services?
42. Is your network currently contracting with any disease management provider
groups? If yes, please describe in detail. If no, please describe any plans for
doing so in the future.
43. Will you coordinate /cooperate with outside disease management vendors?
44. Describe how your organization will communicate the MCBCC schedule of
benefits, changes to the schedule of benefits and general administrative policies
and procedures specific to the MCBCC Medical Plan to providers?
45. Describe how your organization will ensure that providers in your network refer to
network facilities and other network providers?
46. List the hospital selection /evaluation criteria you use. Specify the
certifications /credentials you contractually require hospitals to maintain (e.g.,
licensure, JCAHO accreditation, evidence of liability insurance, etc.). You may
add additional lines as needed.
Contractually Verified
Maintained Annually
Criteria (Yes or No) (Yes or
No)
1.
2.
3.
4.
47. Which of the following healthcare services are not available within the target area
network (Monroe and Miami -Dade County)? What arrangements have been
made to provide these services?
Section Four — PPO Network and Network Management Page 9
a. Alcoholism /chemical dependency (inpatient and outpatient)
b. Ambulatory surgery
c. Cardiac catheterization laboratory
d. CT scanner
e. Emergency department
f. Intensive care unit
g. Neonatal intensive care unit
h. Obstetrics
i. Open heart surgery
j. Pediatric inpatient unit
k. Psychiatric (inpatient and outpatient)
I. X -ray radiation therapy
48. Please indicate if your organization's physician application and credentialing
process requires the following:
a. Written verification of education and experience
b. Verification of current license and DEA certificate
c. Investigation for adverse action on license and /or hospital
privileges
d. Verification of letters of recommendation
e. On -site inspection of physician offices
f. Personal interviews
g. Check malpractice history with appropriate state /federal
agencies
h. Malpractice insurance includes limits of at least $1 million per
occurrence and $3 million aggregate
i. Regular recertification of participating physicians
49. Is the credentialing function delegated? If yes, to whom?
• Hospital
• IPA
• Other (please specify):
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
• Yes ❑ No
I■\'M■1111110C•7
❑ Yes ❑ No
50. Does your organization selectively drop physicians within a medical
group /physician association while continuing to contract with the medical
group /physician association?
51. What was your physician turnover in the past year?
• Family practice physicians, internists, pediatricians, Ob /Gyns
• Other Specialists
52. How often do you visit physicians on -site to explain contracts and contract
changes?
Section Four — PPO Network and Network Management Page 10
53. Do credentialing policies and procedures meet accreditation standards? Yes
No If yes, what accreditation organization?
54. Do you accept client requests to approach specific providers?
55. How long does it take to credential a new physician?
56. Is there a formal committee that sets participating provider quality assurance
policy and reviews treatment outcomes on a regular basis? If so, who is on the
committee and how often does it meet?
57. Describe how quality assurance activities are used to recredential, recontract,
and /or evaluate individual provider performance.
58. Describe how quality assurance activities are used to monitor complaints and
used to improve patient care and service.
59. Describe any education programs for staff.
60. Do you issue separate reports to providers to help them measure their practices
in terms of practice patterns /variations and costs of alternative
treatments /procedures? If so, provide samples.
61. Describe the responsibilities, credentials, and reporting relationships of the
people who work in the quality assurance program.
62. How are disputes or questions handled about reimbursement amounts:
a. Between a patient and the provider?
b. Between the claim payor and the provider?
63. Between recredentialing cycles, do you conduct ongoing monitoring of
practitioner sanctions, complaints and quality issues? Yes No If yes,
how often?
64. Do you perform patient satisfaction surveys? If so, describe and provide
samples and results.
65. Please describe your procedure for evaluating a provider's performance.
66. Describe your criteria for dismissing or dropping a participating physician or
hospital.
67. How many providers have been disciplined or dropped over the past three years
from your network? Please provide the number of physicians terminated in
Monroe County and Miami -Dade County (separately) who failed to maintain
credentialing standards and the number who have been terminated due to quality
Section Four — PPO Network and Network Management Page 11
assurance reasons.
68. Describe the services and features members have access to on your website.
Please provide the URL for your website.
69. Describe your 24 -hour nurse line. Do you report on usage? Yes No
70. Do you process and reprice network claims before they are submitted to the
claim payor? Please describe this process in detail.
71. What fee schedule do you use for out -of- network benefits on the PPO plan? Can
you administer alternate fee schedules upon MCBCC's request?
Yes No
72. What is your target turnaround time for repricing? What is your average actual
turnaround time over the past two years?
73. Can the claim payors' system automatically determine reimbursement for
participating providers?
74.Are there specific third party administrators or claim payment systems you are
unable to work with? Provide a list of third party administrators who are currently
pricing claims for your mutual clients.
75. Will you accept eligibility data in electronic format? If yes, please specify
acceptable formats.
76. Describe in detail your procedure to communicate network changes to the TPA,
employer client, employees.
77. Do you provide hard copy network directories for distribution? If so, at what
cost? Will you provide a PDF file or camera -ready material for MCBCC to
produce and distribute directories?
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four — PPO Network and Network Management Page 12
SECTION FOUR
PHARMACY BENEFITS ADMINISTRATION
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Respond to the questions immediately after the question.
Organization Name:
Primary Contact/Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Answer each question fully. Each answer will be scored on content and ability to
understand and answer the question. Make sure you understand who the client is, what
their plan design is like and what they are looking for from a PBM before you answer the
questions. Do not refer to brochures or other attachments. Summarize information
without compromising the integrity of your answer.
Each question should be listed and numbered and the answer should be found directly
under that question. Do not list the answer as "it is in another exhibit" or "can be found
under another question ", except where specific exhibits or samples are requested.
The Price Offering request should also be filled out as completely as possible.
All proposals will assume to duplicate current benefits and services unless noted
otherwise as deviations in the vendor response section of the RFP.
Any subcontractors or companies who are not wholly owned by your firm must be
identified and the relationship disclosed.
PLAN DESIGN
1. Are the following plan design elements available:
• Calendar year deductible?
• Calendar year deductible followed by percentage co -pay?
• Calendar year deductible followed by percentage co -pay with an out -of-
pocket maximum (single and family)?
• Flat dollar co -pay generic, percentage co -pay brand?
• OTC Drugs coverage as tier one or tier two?
• Co- payment based on Lifestyle changes? i.e. cholesterol levels, weight loss,
etc
• Three -tier co -pay: flat dollar for generic, flat amount or percentage for multi -
source, flat amount or percentage for single source?
• The greater of a flat dollar amount or percentage co -pay (e.g., greater of
$10 or 20 %)?
• Cash and carry reimbursement (managed indemnity)?
• 100% member co -Pay at the point of sale (discount card)?
• Four tier program with specialty Rx?
• Fifth Tier Program for lifestyle drugs?
• Separate deductibles within therapy classes?
• Co- payment based on quantity for certain products i.e. Bottles of Insulin,
Pain Meds, PRN meds or any other medication where the dose may vary
each day?
• Mail order Co -pays at 2X retail, 2.5 X retail and 3 X retail available? Which
do you recommend and why?
2. Explain how out -of network claims are processed. If extra charges apply,
explain.
3. Can pharmacies access your service representatives 24 hours /day? If not,
what hours are available? Is a pharmacist available 24 hours a day? Explain
any IVR system and how it works with the pharmacies.
4. Can certain drugs be limited to a specific diagnosis, specific specialty or require
pre- authorization or step- therapy? Can certain drugs be limited to certain
quantities and certain length of therapy?
5. Is your pre- authorization process administered in -house or by a third party? Do
you have Administrative pre- authorizations and clinical pre- authorizations? How
are they different? What are the charges for each?
6. Can you administer plans that include non - Federal Legend (OTC) drugs? Can
you place on first, second or third tier?
7. Do you have the ability to provide a coordination of benefit (COB) provision?
Please explain. Are there any charges for this process?
8. If a drug is denied or not covered explain how medical necessity is determined
and then managed.
9. How many Pharmacists do you currently employ? How many are PharmUs?
What positions do they hold in the company? Please be specific. Differentiate
clinical, account management and executive positions.
10. What is the fee per claim for paper claim filing? Describe the Paper claim
process.
MAIL SERVICES
11. Do you have your own mail service prescription drug program? If so, is it fully
integrated with your retail network?
12. Do you subcontract with an outside mail service vendor? If so, which mail
service vender do you use and how is mail order integrated with your retail
program?
• Is the mail service plan integrated with your retail program for utilization
review and reporting?
• Is the mail service plan integrated with your retail program and eligible for
formulary rebates?
13. At what capacity are your mail services? If more than one location, give the
capacity at each location.
14. Explain your disaster plan for your mail operation. Explain what will happen if
your mail facility cannot process prescriptions.
15. Where is your mail service facilities located?
16. What is the guaranteed turnaround time for "clean" mail services prescriptions?
Explain how the turnaround time is calculated? Date stamp on receipt or when
it arrives in pharmacy? Please be specific.
17. What is the average turnaround time for "non- clean" Rx's? ( those prescriptions
that require an additional interaction)
18. How many Rx's go through your mail system each year? Please provide
prescription accuracy percentages for your mail service program (please
provide for the past 2 years). What strategies do you utilize to improve your
accuracy going forward?
19. What standard usage percentage do you use for mail order refills? Explain why
you use that percentage. Can this percentage be specified by the client?
20. How do you determine days supply on topical products, insulin, PRN
medications and any other medication where the dose can vary at each therapy
occurrence?
21. What is the standard minimum and maximum days supply available through
your mail order program? Can you fill a 35 day Rx at mail and at retail?
22. Do you support a 90 day at retail program? Please include your average pricing
for this program including rebates.
23. Describe your Specialty Pharmacy Program including its integration with your
traditional mail and retail programs. How would you integrate with the client's
medical plan?
PRICING
24. Provide a listing of standard programs and services that are included in your
base pricing arrangement.
25. Do you provide guaranteed discounts for retail brand and generic medications?
26. Do you provide guaranteed discounts for mail brand and generic medications?
27. Do you charge an administrative fee?
28. Is your pricing Transparent or traditional or a hybrid? Please describe and
differentiate.
29. Provide a listing of additional services and their applicable costs.
30. Please provide book of business pricing per unit and per day (and other
specified information) for the past 6 months as of January 2009 for the top
drugs on Excel file —(file provided -just fill in ingredient cost information- exclude
rebates, dispensing fees, admin fees, co- pay's, and taxes.
31. Maximum Allowable Cost (MAC) program
• How is MAC pricing established?
• Are various MAC pricing levels available or do you have only one set of
MAC pricing? If more than one explain why.
• Of the total generics available on the market what percentage of those
are on your MAC list.
• How many drugs are on your MAC list? Define by number of GPI's and
NDC's.
• How is it updated? How frequently?
• Provide full MAC list by GPN or GPI (sample file provided with RFP)
32. What is your MAC program baseline discount? Do you guarantee?
33. How often does your MAC pricing baseline change? Be Specific.
34. Do you use a maximum reimbursement amount and is it different than a MAC?
Explain how.
35. If claim is rejected is there any additional administrative charge and if so who is
charged?
36. Do you utilize a U &C clause in your contracts with network pharmacies? If so
do the claims still adjudicate through the system? Is the payor charged a
dispensing fee?
37. Do you have a U &C in the mail service? Is there a U &C with a 90 day at retail
program?
38. Describe how you work with the network pharmacies to increase generic
utilization. Describe any incentives or fees paid to the network pharmacies to
increase utilization.
39. In a MAC program, explain how DAW -1 and DAW -2 prescriptions are expensed
to the Plan participant under:
• A mandatory generic program.
• A non - mandatory generic program.
40. Under any circumstances does the patient get penalized if the pharmacy is out
of stock of a generic under your mandatory generic program?
41. Which pricing guide do you use for brand AWP? How often do you update
pricing in your system?
42. Does the contract pricing negotiated with pharmacies allow your organization to
keep the differential between the contracted amount and the amount billed to
the client (spread pricing)?
• If your organization keeps the differential, please identify the pricing your
organization negotiates with the pharmacies in each of the respective
networks under review.
43. Do you employ any negative spread in your retail brand discounts?
44. Do you employ any negative spread in your retail dispensing fees?
45. Does your mail service provide re- package any medications and then use a
different NDC to increase reimbursement?
46. How long is your financial quote guaranteed for?
47. What additional charges (ex. Clinical programs, ad hoc reports) are included in
your quote if not covered under question six?
48. List your generic strategy and specific programs to encourage the use of
generic medications. How will your company increase generic fill rates to take
advantage of the multiple products going generic over the next three years?
49. Will you guarantee a generic utilization percentage? What data will you need to
develop a guarantee? How long is the guarantee?
50. Do you have a step therapy program to increase generic penetration rates
within certain therapy classes and if so what classes?
FORMULARIES AND REBATES
51. How is your prescription formulary developed and administered?
52. Are the formularies based on the lowest cost prescriptions available? If not
describe how the financials are calculated into the preferred and non - preferred
products.
53. Do you offer a closed formulary or generic only formulary?
54. What types of open or restrictive formularies are available?
55. Do all drug manufacturers whose products are listed as preferred in your
formulary provide rebates? What percentage of preferred products has
rebates?
56. Do any non - preferred products get rebates? What percentage?
57. What percentage of total formulary products has rebates?
58. How are the rebates shared with the plan sponsor?
• Are the rebate dollars paid to the plan sponsor via check or are credits given
retrospectively or prospectively?
• Can you pay rebates at point of service?
• Do You have a 100% pass through
• Do you have a shared rebate program? Please describe.
• Do you have a program where you retain rebates for administrative and or
other fees?
59. Explain the structure and function of your Pharmacy and Therapeutics
Committee. How often does your Pharmacy & Therapy (P &T) committee meet
and how often does a therapy class get reviewed?
60. How do you report rebates to the client? Are audits available? If so, how are
they done? Are audits down to the drug level or only to the aggregate rebate
level?
61. Do you have an individual at your company who manages the formulary and if
so what is his /her name and qualifications?
62. How long after plan inception are the first rebate shares paid and in what
intervals thereafter?
63. Assuming rebates are paid per unit are retail and mail prescriptions paid at the
same level? If not explain why.
64. Can specific formularies be developed for clients? Will this custom formulary
affect rebate rates?
65. Do you share rebates on specialty (injectable) medications? If so please
indicate either the number of product rebate contracts or the percentage by
Dollar volume of specialty products that do receive rebates.
66. Do you guarantee rebate dollars per claim retail and mail? Rebate dollars per
brand claims only or rebates per member per month or any other rebate
formula?
67. Do you accept any rebates administrative fees and if so what is the average
percentage?
68. Do you accept any commissions, therapeutic interchange fees, communication
fees or any other fees or payments from Pharmaceutical companies?
PHARMACY CONTRACTING
69. Do all network pharmacies have the same contract rates? If not explain how
contracts are negotiated and developed.
70. Do you have pass through network pricing available?
71. Do you or can you develop custom networks? Please describe and indicate any
contract differences.
72. Can you manage an in network and out of network plan design for pharmacies?
73. What percentage of your pharmacy network is online? If not 100% explain.
74. How many claims do you process per month? What is your capacity?
75. Do you run geo- access models to determine percentage of members within a
given radius?
76. In the last year where client data is available, what percent of claims were
rejected?
77. Please give historic data on rejected claims for the last two years by category
and give the percentage for each as a percent of all claims submitted.
78. Can a client request a pharmacy be added to the network? If so how long does
it take to become fully operational where Rx's can be filled there under the
clients plan?
79. What is the mechanism for plan members to request network pharmacy
additions? Is there a phone number?
80. How frequently are pharmacies paid? How are they paid?
81. Are pharmacies paid what the client is billed?
82. Do you re- negotiate pharmacy contracts? How long is the normal pharmacy
contract? How does that new contract affect your existing clients if there is an
increase in discounts?
83. How do you manage the quality of services provided by your network
pharmacies? How does a client report a service issue? How often are
pharmacies reviewed? How many pharmacies were removed from your
network last year and why?
84. Do you participate in pharmacy withholds? If so, are copies of pharmacy
remittances available for audit?
THIRD PARTY FEES
85. Do you pay fees or provide reimbursement to any of the following:
• Physicians- Formulary Compliance? Generic Rx rate? Other?
• General agents? Marketing fees, survey fees?
• Insurance agents /brokers /consultants? Commissions?
• Pharmacy consultant service fees?
• Marketers?
• Pharmaceutical manufacturers
• Pharmacies? Other than dispensing fees.
• Insurers, third party administrators?
• Switch operators? Envoy, NDC etc?
• Electronic Processors?
If so, please explain the fee /reimbursement structure.
MEMBER SERVICES
86. Does your plan have a 24 -hour toll -free number for member services? Is it an
IVR or does a real person answer?
87. If not, what are your hours of operation?
88. Does the mail order program offer an online method to order refill prescriptions
and explain how it functions. Does the program offer email reminders on
prescription refills?
89. Can members review their preferred drug listing (formulary) on -line?
90. Does the member get a comparative list of medications to those they are taking
that indicates lower cost alternative products are available? Does the program
show the cost savings for the member? For the plan? Is this available online?
Via a letter to member? Via a letter to the physician?
ELIGIBILITY /MAINTENANCE SERVICES
91. Do you offer on -line eligibility maintenance for all clients?
• If so, is there a charge?
• Is there a charge for hard copy maintenance?
• Explain how it works
• How often can changes be made?
92. How do you insure that terminated members are removed from coverage? Will
their client be held accountable for any charges if a terminated member
receives benefits?
93. Are employees and dependants listed separately? Can their pharmacy
utilization be reported separately? How do you manage multiple dependants
with the same birthday? (Twins, Triplets, etc.)
94. Since eligibility is determined online at point of sale, do you have a 1 -800
number the member can call if there is problem? Are dependents listed by
name on the pharmacy card? Or is only the employee listed on the card?
95. How often is membership updated? Can the membership be updated online by
the client? Can this be done daily?
96. Are there any charges for membership cards? How many are included initially?
97. Can you do a combination medical /Rx card? Is there any additional charge for
this?
98. Can you put the plan sponsor name and logo on the Rx card? Is there any
additional charge for this?
99. What is the charge for replacement cards?
100. What is the maximum number of Rx cards allowed per family without any
additional card production charges?
101. Can integrated ID cards be developed with a Medicare part D plan?
102. Can you report Rx savings each month with billing statement?
REPORTING SERVICES
103. What are your reporting capabilities? Please attach a portfolio of all available
reports. Each should have a short description.
104. Which reports are provided as standard? How often are they generated?
105. What is the fee for non - standard report production? Is this fee generated on a
fixed cost per report or billed on an hourly basis? Give examples of non-
standard reports.
106. How long does it take to get requested non - standard reports? What is the
process to request a non - standard report?
107. Are reports available online? How many people can get access? Can the client
request their consultant have online accessibility? Is there a charge for online
accessibility? Any special computer specifications needed to get online
reports?
108. How often are reports provided and can they be reported by division, location,
department or union subdivision within a single employer group at no additional
charge?
109. Are paper and electronic claims all included in the reports?
110. Does the client have the ability to access your database in real time for
purposes of adds /deletes, tracking plan experience, utilization patterns, and
other available plan information?
111. How is this ability provided? Is there any additional charge to the client? What
is the minimum size group for this service?
112. How can client reports be provided? CD, Disk, and paper? Is there any
additional charge for this? How often are reports generated?
113. How is data benchmarked for the client? Are their geographic and demographic
benchmarks?
114. Is your reporting system capable of reporting single /couple /family membership
participation on a month -to -month basis?
115. Do you own your electronic claims adjudication system or do you contract with
an outside vendor? Is so, whom?
116. Do you track and monitor prescription utilization outliers?
• Physicians
• Pharmacists
DRUG UTILIZATION REVIEW
117. Please describe your all clinical cost management programs and do you
include any of the following:
• Anti - fungal
• Appropriateness of use
• Daily Average Consumption
• Gastrointestinal
• Generic Solutions
• Maximum Daily Dose
• Migraine
• NSAIDs
• PAIN medication
• Substance Abuse
118. Do you report clinical savings each month? Can you guarantee savings?
119. Do you conduct pharmacy audits? If so, what percent of claims and /or
pharmacies are audited on an annual basis? What is the average amount
recovered in an audit?
120. Does your company hire external auditors? How do they charge for the
service?
121. What is the distribution of the money recovered as a result of either claims or
pharmacy audits?
122. How do you manage specialty /Injectable drugs? Do you own your own
specialty pharmacy? Do you rent specialty pharmacy services? Who is your
vendor? How long is your contract with that vendor?
123. Please provide an Injectable drug /specialty drug list in an attached Excel file
with your recommendations for coverage.
124. Please provide a top 30 specialty drug list (file provided)
125. Provide a complete specialty pharmacy list with discounts. (sample file
provided)
126. Do you provide administrative Prior authorization as part of the basic package?
127. Do you provide clinical prior authorizations and what is the charge for this
service?
128. Do you have step therapy programs? Please describe how the program works?
129. Can you do a step therapy program within a specific therapy class?
IMPLEMENTATION & ADMINISTRATION
130. What is the shortest lead time you can implement a group?
131. What mediums do you accept for plan enrollment?
132. Do you require a deposit? If so, how much do you require?
133. Can the deposit requirement be waived? What are the requirements for this?
134. Please explain your billing procedures and attach a sample list billing.
• How frequently are clients billed?
• What charges do billings encompass?
135. Can a plan sponsor be issued separate billings for employee subdivisions, such
as locations, divisions, union /non - union, etc.?
NETWORK MANAGEMENT
136. Please provide a copy of your most recent annual report.
137. Are you a licensed TPA? If so, in what state?
138. Are you a Pharmacy Services Administrative Organization (PSAO)? If so, in
what state are you domiciled?
139. Are any drug manufacturers, distributors, or pharmacy organizations in an
ownership, day -to -day management, or board of director positions with your
company?
140. What company /individuals maintain equity in your PBM?
141. How long has your PBM been in the business of managing a prescription drug
benefit?
142. How many FTE's or full time employees work for your company? How many
Pharmacists and how many of those are Pharm.D's.
143. Is your plan for - profit or not - for - profit? If not - for - profit, under which IRS code do
you operate?
144. Is the employer (plan sponsor) held harmless for negligence on the part of the
participating pharmacy?
145. With which transaction company does your network contract?
• ENVOI
• NDC
• GCC
• Argus
• Other
146. Are all switching charges paid by the pharmacies? Are there any exceptions?
147. Do you sell, distribute or provide any claims data and client information to
outside vendors? If so describe.
148. Is your PBM or any part of your PBM in the process of being sold, merged or
disbanded?
149. Does your PBM carry an Errors & Omissions policy? Please attach a copy of
the face sheet.
• If yes, who is the carrier and what is the expiration date of the policy?
• What are the policy limits and deductible?
• Is the contract a claims -made policy
150. Do you carry a comprehensive general liability policy? Please attach a copy of
the policy face sheet.
• If yes, who is the carrier and what is the expiration date?
• What are the policy limits and deductible?
151. Does your company carry a fidelity bond? Please attach a copy of the policy
face sheet.
• If yes, who is the underwriter?
• What is the expiration date of the policy?
• What are the limits and coverage for the policy?
• What is the deductible?
• What are the co- annual aggregate funds held for all clients?
152. Have claims been made against any of these policies within the past two
years?
153. Please provide a copy of your service fee agreement.
Information and Financial Exhibits
Include with this RFP in an Excel file
1. The top 100 retail drug list, the top 50 mail drug list and top 30 specialty drug list
as provided to you in this RFP, filled out completely as indicated in the RFP
request materials
2. Complete Specialty drug lists with discounts. Include all options available to
client. (Sample file provided)
3. Provide a full MAC list indicating cost per unit pricing ( Sample file provided)
4. Implementation program (Excel if possible but not required)
5. Complete PBM Vendor Price Offer worksheet completely. Do not leave any
questions blank.
/_1 MOT MINro15 i
1. Annual report
2. Pricing- Provide on PBM Vendor Price Offering Worksheet (included)
3. Executive Summary of your firm
4. Overview of how you manage the pharmacy benefit
5. Reports- Standard, Executive, Ad hoc.
6. Examples of member communications
7. Website examples
8. Sample agreement
9. Provide a sample of your standard performance guarantee contract.
10.The performance guarantee will be very important in determining the final
vendor. The following parameters will need to be included in the final
performance guarantee contract.
• Account management performance
• Average speed to answer a customer service call
• Customer service quality
• Abandonment rate
• System downtime
• Quarterly and monthly management report timing
• Invoice production
• Claims processing turnaround
• Claims processing accuracy
• Claims financial accuracy
• Mail turnaround
• Mail dispensing accuracy
• Quarterly meetings
• Geographic access
11. Are the performance guarantee parameters account specific or based on your
book of business? If based on book of business, please describe.
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
SECTION FOUR
SPECIFIC AND AGGREGATE STOP LOSS INSURANCE
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Attach separate sheet for answers.
Company Name:
Primary Contact/Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Please respond in the corresponding right hand column.
GENERAL INFORMATION:
1.
How long has your organization been in business?
Has your company done business under other names? If
yes, please provide historical background information.
Identify any interests your organization may have with
associated vendors (claims administrators, brokerage firms,
managed care firms, etc.).
Have you ever been suspended from writing this line of
coverage? If yes, please describe.
Year established:
Yes No
Yes No
2.
Is your organization licensed to do business in all 50 states
and U.S. territories? If no, identify the states /territories in
which you are not currently licensed.
Yes No
3.
What percentage of the risk does your company assume? If
less than 100 %, please identify additional reinsurer(s) and
the respective percentage of assumed liability.
In what month do your reinsurance treaties renew?
%
4.
How many excess loss clients do you currently have?
How much annualized premium do these clients represent?
$
5.
Please provide your current A.M. Best rating.
AM Best:
6.
Please describe your disclosure process for pre -sale and at
renewal (if different).
7.
Please provide a copy of your reinsurance contract and any
amendments.
When was the enclosed contract adopted?
Please provide a copy of your disclosure statements.
Included
Included
8.
In most cases, we require that your organization work
directly with Gallagher Benefit Services rather than our
client's claims administrator (TPAs, BCBS plans, carriers,
etc.) on such things as:
➢ Renewals
➢ Specific & Aggregate contract concerns
➢ Plan Document /SPD adoption / approval
➢ Plan amendments
Agree
Disagree
PROPOSAL:
9.
What is the minimum group size for which your company will
issue a proposal?
employee
lives
10
What industries (if any) does your company consider to be
"preferred "? Please list.
11
What industries (if any) does your company consider to be
"ineligible "? Please list.
12
For public entities, do you have any restrictions on percentages
of certain types of employees, such as police and fire
employees?
%
N/A
13
Is your organization able to work with any claims
administrator (TPAs, BCBS plans, carriers, etc ?)
If no, provide a listing of all U.S. based claims administrators
with whom your organization will do business. Please also
indicate those that may have a "preferred" status and
describe the advantage to the client in doing business with
these claims administrators.
Yes No
14
Is your organization's excess loss contract guaranteed
renewable?
If not, describe your determination and notification methods.
Yes No
15.
Does your second year contract automatically renew as a
paid contract?
Yes No
16
Is your organization capable and willing to contact the
claims administrator (TPAs, BCBS plans, carriers, etc.) or
Case Management firm directly to obtain additional
information related to large claimants?
Yes No
17
When do you consider claims experience to be fully
credible? Please describe.
18
Coverage is based on a no -loss / no -gain full transfer of
coverage basis. If disagree, please explain.
Agree
Disagree
19
Gallagher Benefit Services desires firm rates at least 30
days (90 days for public entity clients when necessary) prior
to sale. If disagree, please explain.
Agree
Disagree
20
Gallagher Benefit Services considers coverage to be
"bound" when the new carrier is in receipt of the binder
check or first month's premium payment and executed
application. Do you agree with this statement? If disagree,
please explain.
Agree
Disagree
21
Once firm rates are presented and coverage is bound, under
which circumstances, if any, would your organization modify
rates / factors mid year?
22
Are you able to propose a terminal liability option for a group
that may, at some point in the future, choose to convert to a
fully- insured arrangement?
What is the cost to include this option?
Is this option available at initial policy issue and also at
renewal?
Yes No
Cost: $ / ee / mo
or additional %
Yes No
23 Does your organization offer "preferred" pricing based upon Yes No
the client's network(s)?
If yes, provide a listing of the networks your organization has
rated, identify the status level for each and the associated
percentage of savings discount.
24
Gallagher Benefit Services will receive no commissions on
this case. Can you accommodate rates net of commission?
25
Do you require that the prospective client purchase
additional lines of coverage in order to bind stop loss
coverage with your organization? If yes, outline your
requirements.
Do you offer pricing consideration when multiple lines of
coverage are purchased? If so, please provide details.
Yes No
26
Do you limit the percentage of covered lives that are
COBRA and / or retirees? If so, please provide details.
Yes No
SPECIFIC:
27
What is the minimum individual specific deductible your
company offers?
$
28
What percentage discount / credit is applied to your "first
year" (i.e., 12/12) specific pricing?
29
How long are your specific rates guaranteed?
Are you willing to guarantee these rates for a period longer
than twelve months? If so, how would this impact rates?
Yes No
30
Please describe the specific incurred /paid contract periods
(i.e., 12/12, 12/15, etc.) that you offer.
31.
Is there a run -in limit on specific stop loss?
Yes No
If yes, what is the percentage or formula?
32
What is the maximum individual lifetime maximum amount your
$ million per
contract recognizes as eligible (i.e., $2 million, $5 million,
individual
unlimited)?
Yes No
Do you have more than one option available?
33
Confirm that your specific coverage(s) can include the
following benefits:
Yes No
Medical
Yes No
Prescription Drug
34
Do you laser individuals at policy inception?
Yes No
Do you laser individuals at renewal? If yes, indicate whether
Yes No
this applies only to those Iasered under the initial contract
terms, or if potentially large claimants are reviewed annually.
If you do not laser, will you laser upon request and offer a
lower premium?
Yes No
If you do laser, will you offer a premium increase instead of
Yes No
the laser?
35.
Can your organization offer the specific deductible on a
❑ Standard
standard, aggregating and / or family basis?
❑ Aggregating
❑ Family
❑ Other
AGGREGATE:
36
What percentage discount / credit is applied to your "first
year" (i.e., 12/12) aggregate pricing?
37
How long is your aggregate premium guaranteed?
Are you willing to guarantee these rates for a period longer
than twelve months? If so, how would this impact rates?
Yes No
38
Please describe the aggregate incurred / paid contract
periods (i.e., 12/12, 12/15, etc.) that you offer.
_
39
Confirm that your aggregate coverage can include the
following benefits:
Medical
Prescription Drug
Yes No
Yes No
40
At what percentage of expected claims can the aggregate
corridor be set?
Can you quote more than one option?
❑ 110%
❑ 115%
❑ 120%
❑ 125%
❑ Other
Yes No
41. Do you retain the right to modify your aggregate factors Yes No
based on experience subsequent to the proposal?
42
Does your aggregate contract impose an annual maximum
claim liability? If yes, identify the amount.
Are there any other options available?
Yes No
$
Yes No
43
Please describe the specific incurred / paid contract period
(i.e., 12/12, 12/15, etc.) that you offer.
47.
What information do you require from the client, their claims
administrator and / or Gallagher Benefit Services to issue a
renewal? Be specific regarding all claim experience and
disclosure requirements.
44
What percentage, if any, of annual paid claims applies to
initial run -in limitations on your aggregate contract?
Will your organization waive run -in limitations? If yes, at
what cost / percentage?
% N/A
Yes No
$ / %
45.
What is your minimum attachment point percentage or
formula for first year cases?
Does this differ for renewals?
Yes No
RENEWAL:
46
Many of our clients require preliminary renewal information
from their vendors 180 days in advance of their actual
renewal. Is your organization able to comply with this
request? If no, explain.
Yes No
47.
What information do you require from the client, their claims
administrator and / or Gallagher Benefit Services to issue a
renewal? Be specific regarding all claim experience and
disclosure requirements.
48
We require renewal rates and factors to be finalized no later
Agree
than thirty days prior to the date of renewal. If disagree,
Disagree
51
explain.
49
What contract features are subject to adjustment from
preliminary to final renewal?
53
When do you consider a claim paid? Please be specific.
Specific Rate(s)
Yes No
Aggregate Factor
Yes No
Who defines what the reasonable and customary amounts
are?
Aggregate Rate
Yes No
CLAIM REIMBURSEMENT:
50
What are your proof of claim and timely filing requirements
for claim reimbursement requests?
51
What are your company's timing requirements with respect
to notification and claim filing?
52
Who has final claim decision - making authority with respect
to specific and aggregate claims?
53
When do you consider a claim paid? Please be specific.
54
Who defines what the reasonable and customary amounts
are?
55
Explain your organization's underwriting guidelines for
incorporating plan changes.
Must plan changes be approved in writing prior to
implementation and / or renewal?
Yes No
56
Do you designate a Large Case Management firm with
whom the claims administrator (or Pre -cert vendor) must
coordinate potentially catastrophic cases?
Yes No
57
Are there any conditions or circumstances (i.e., diagnosis,
procedure, medical services, etc.) that require pre - approval
by your case managers? If yes, please list.
Yes No
58
Is there a Transplant Center of Excellence provision in your
contract?
If so, is this a voluntary or mandatory program? Explain the
consequences of non - compliance.
If voluntary, do you offer any discounts for including it in the
plan?
Yes No
Yes No
Yes No
59
Are case management fees reimbursable to the client?
Are case management fees included in an individual's
lifetime maximum benefit calculation?
Yes No
Yes No
60
Will you allow "non- covered" alternative care, if approved by
your case managers?
Yes No
61.
Are there any charges and /or fees that standardly do not
apply to specific or aggregate coverage?
Yes No
62
Provide a listing of all specific conditions or diagnosis your
organization considers to be "catastrophic ".
63.
If the client is a health care facility or provider (i.e., hospital,
physician group), are charges performed at their facility
reimbursed at a lesser amount than other charges?
Yes No
64.
Does your contract recognize all eligible employees, spouses,
domestic partners, dependents, FMLA, retirees (if applicable),
and COBRA beneficiaries as defined by the employer's Plan
Document / SPD?
Yes No
65
Other than the employer's Plan Document / SPD, does the
contract allow for guidelines found in the employer's
Employee Handbook (i.e., leave of absence policy)?
Yes No
66
Is there ever a situation in which you would deny a claim
that was a covered benefit in an employer's Plan Document
/ SPD you had previously approved?
Yes No
67
Please identify any restrictions and limitations pertaining to
an off - anniversary termination.
68
Please detail the process involved in obtaining coverage for
out -of- contract services.
69
If PPO access fees are payable as a percentage of savings,
are the charges in excess of the specific deductible
reimbursed?
Yes No
70
Your contract must waive "Actively at work" provisions,
based upon HIPAA guidelines.
Agree
Disagree
71 If a client acquires a new company during the contract year,
are you willing to waive the actively at work, dependent non -
confinement and pre- existing condition limitation provisions
for the newly acquired employees, their dependents,
spouses, domestic partners, FMLA, retirees (if applicable),
and COBRA beneficiaries?
72
Yes No
Gallagher Benefit Services desires that the employer's Plan
N /A, all provisions will
Document / SPD be the controlling document for all claim
mirror plan documents /SPD.
determinations. If your contract does not rely on the employer's
Plan Document / SPD for stop loss claim determination, please
explain your organization's position regarding coverage for the
listed provisions.
a) Work - related exclusions (worker's compensation vs.
_Match SPD
any gainful employment)
_No, stop loss contract
b) Pre - existing Conditions
prevails
_Match SPD
_No, stop loss contract
prevails
c) Non - medically necessary charges
_Match SPD
_No, stop loss contract
prevails
d) Experimental and investigational procedures, drugs
_Match SPD
or treatment
_No, stop loss contract
prevails
e) Biologically -based mental disorders
_Match SPD
_No, stop loss contract
prevails
f) Non - biologically -based mental /nervous, alcohol and
_Match SPD
substance abuse
_No, stop loss contract
prevails
g) Administrative, investigative and legal services,
_Match SPD
including compensatory & punitive damages
_No, stop loss contract
prevails
h) Charges recoverable by a third -party (subrogation
_Match SPD
and /or Medicare)
No, stop loss contract
prevails
i) Expenses that are incurred as a result of war
_Match SPD
_No, stop loss contract
prevails
j) Expenses that are incurred as a result of an act of
_Match SPD
terrorism on domestic and foreign soil
_No, stop loss contract
prevails
k) Expenses incurred while committing assault / felony
_Match SPD
_No, stop loss contract
prevails
I) Charges related to attempted suicide
_Match SPD
_No, stop loss contract
m) Charges related to self - inflicted injuries
prevails
_Match SPD
_No, stop loss contract
prevails
n) Charges related to hazardous pursuits
_Match SPD
_No, stop loss contract
prevails
o) Please include any other significant provisions
which you feel need to be addressed and your
organization's position regarding those provisions.
73
Identify whether your excess loss contract has any limits
N /A, coverage for
related to the following provisions:
all benefits are provided
as covered in the
employer's Plan
Document / SPD.
Limitation Detail
a) Late Entrants
a)
b) Annual Open Enrollment
b)
c) Section 125 - qualified change in status events
c)
d) Domestic Partner coverage
d)
e) Transplants (describe any requirements and
e)
limitations)
f) Biologically -based mental disorders
f)
g) Non - biologically based mental /nervous and /or
g)
substance abuse
h) Alternative therapies (e.g. acupuncture,
h)
homeopathic or naturopathic, etc.
i) Attempted suicide (whether sane or insane)
i)
j) Acts of war
j)
k) Acts of terrorism on domestic and foreign soil
k)
1) Commission of a felony
1)
SPECIFIC:
74
What is your organization's average turnaround time for
days
specific claims submitted for reimbursement?
75
With respect to specific claims submitted for reimbursement,
please describe any limitations (i.e., minimum dollar
amounts).
76.
Is the maximum benefit for specific excess loss the plan's
lifetime maximum amount less the specific deductible?
Yes No
77
Do you offer advance funding or quick pay options for
specific claims? If so, please provide details including any
additional cost.
Yes No
78
When do you require notification of a specific claim?
% of
Specific Deductible
Amount, or
AGGREGATE:
79
If there is an aggregate claim, is an audit part of your
standard process?
Yes No
80
What is your organization's average turnaround time for
aggregate claims submitted for reimbursement?
days
81
With respect to aggregate claims submitted for
reimbursement, please describe any limitations (i.e.,
minimum dollar amounts).
82
Do you offer advance funding or quick pay options for
aggregate claims before end of plan year? If so, please
provide details, including any additional cost.
Yes No
83
How often do you require aggregate claim reporting
information?
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
SECTION FOUR
WELLNESS SERVICES
QUESTIONNAIRE
Please complete a separate proposal form for each service you wish
to offer. Respond to questions immediately after the question.
Organization Name:
Primary Contact/Representative:
Title:
Address:
City, State, Zip Code:
Telephone Number:
Fax Number:
E -mail Address:
Submit responses in Hard Copy and Electronic Version in a useable Microsoft
Word format.
1. Provide your program delivery staffing stricture to include number of employees,
experience, credentials, education and role in each area.
Section Four - Wellness Page 1
# of Staff
Avg. Yrs
of
experience
Required
credentials &
education
Role in
program
deliver
Health Educators
Exercise Physiologist
Registered Dieticians
Communication Support Staff
Health Coaches
Managers
Customer Service
Representatives
Other - Please describe:
Section Four - Wellness Page 1
2. Provide a description of the ongoing management of your services for this client.
3. Identify who is designated to monitor and report participation and employer satisfaction.
4. Provide an implementation plan, including task, timeframes and resources. Do you have
implementation managers or other personnel dedicated to the implementation process?
Provide a brief explanation of this role.
5. Will you assign an onsite Wellness Coordinator to MCBCC to facilitate program
development and coordination of Wellness Activities? Please provide pricing for this
service.
6. Describe your program audit process to ensure satisfactory program participation and
continued member engagement.
7. If MCBCC attains target participation levels, will you consider a reduction in cost?
Please describe how this would work.
8. Indicate your hours of operation for the following areas (please utilize the Eastern
Standard time zone):
CLIENT PROFILE
1. List the percentage of your target Lifestyle Management Programs clients by size:
Population Size
HOURS OF OPERATION
% of Client Base
Less than 1,000 employees
MONDAY — FRIDAY
SATURDAY
SUNDAY
From
To
From
To
From
To
Account Team
%
F TOTAL
100%
Customer Service
(automated voice messaging
service)
Counselors (Inbound)
Counselors (Outbound)
After Hours Support
Other:
CLIENT PROFILE
1. List the percentage of your target Lifestyle Management Programs clients by size:
Population Size
# of Clients
% of Client Base
Less than 1,000 employees
%
1,000 — 1,500 employees
%
1,501 — 5,000 employees
%
5,000+
%
F TOTAL
100%
Section Four - Wellness Page 2
2. List Business /Industry of clients:
Type of Business/ludustry of
Client
# of Covered
Lives
% of Client Base
Government
%
Private incl. not - for - profit
%
Other:
%
TOTAL
100%
3. Show client growth base for last 5 years:
2006 2007 2008 2009 2010 2011(Projected)
# of Clients
PROGRAMS
Complete the chart below for each service your organization provides, check all that
apply:
2. Complete the chart below for the Lifestyle Management Programs you provide:
Section Four - Wellness Page 3
OUTSOURCED
DELIVERY MODE
VENDOR
Seminars /
Direct
One on
Online
Telephonic
Onsite
Name of Vendor
Mail
one
counseling
Health Risk
Assessments (HRA)
Biometric Screenings
Health Coaching
Health Education &
Awareness
Campaigns
Self Directed
Programs
Other:
Other:
2. Complete the chart below for the Lifestyle Management Programs you provide:
Section Four - Wellness Page 3
Provide details on how your programs remain current based on research and industry
trends.
4. Describe the medical staff and/ or advisory board who are responsible for reviewing your
programs.
5. Provide your organizations guidelines for program content.
6. Describe enrollment strategies (opt in, opt out, claims data. etc,).
7. Describe your "pro active" approach if programs are opt in or passive enrollment.
8. Provide the process for a participant to dis- enroll in the programs. Is there a penalty if a
member dis- enrolls? If so explain.
Section Four - Wellness Page 4
Lifestyle
Management Programs
- Delivery Mode
Direct
Mail
Self
directed
programs
Telephonic
Coaching
Onsite
Seminars
Lunch and
Learns
One on One
Counseling
Other
Heart Disease
Diabetes
Cholesterol
Hypertension
Asthma
Nutrition
Fitness &
Exercise
Women's
Health
Men's Health
Self Care
Smoking
Cessation
Weight
Management
Stress
Management
Other:
Other:
Other:
Provide details on how your programs remain current based on research and industry
trends.
4. Describe the medical staff and/ or advisory board who are responsible for reviewing your
programs.
5. Provide your organizations guidelines for program content.
6. Describe enrollment strategies (opt in, opt out, claims data. etc,).
7. Describe your "pro active" approach if programs are opt in or passive enrollment.
8. Provide the process for a participant to dis- enroll in the programs. Is there a penalty if a
member dis- enrolls? If so explain.
Section Four - Wellness Page 4
9. Provide a list of the tools available to program participants (goal setting activities,
interactive tools, action plans, journals, etc,).
10. Describe all programs available to Monroe County Board of County Commissioners.
Are they incentive based?
11. Include the cost and number of initiatives available annually.
12. Identify incentives available for each program.
13. Describe your capabilities to manage incentives.
14. Describe your strategy to drive participation and maintain participant engagement.
15. Indicate participation and completion rates for clients you have provided the following
type of initiatives:
• Walking programs
• Exercise programs
• Weight loss challenges (total weight loss)
• Nutrition programs
• Other
16. Does your company have the ability to offer and participate in benefit fairs?
17. Describe any programs which would address the unique needs of an organization with
multiple locations throughout a large geographical area.
18. Does your company limit the number of people who can participate in online seminars
and /or other programs offered online?
19. Describe your capabilities to manage or offer the following on a national basis, check all
that apply:
Section Four - Wellness Page 5
SERVICES
OUTSOURCED
VENDOR
Community
Name of
Service
Offer
Manage
Coordinate
Partnership
Vendor
not
offered
Fitness Center
discounts
Weight Loss
competitions
Stress Management
(Yoga, Tai Chi, etc)
Section Four - Wellness Page 5
MARKETING AND COMMUNICATIONS
Provide samples of a generic communication strategy for our client. Include all aspects,
target audience and roles of account team, including your Wellness Coordinator. Include
creative ideas to promote optimal participation.
2. Do you have standard communication materials that support your programs and services?
If so, are the materials customizable and to what extent?
3. Describe your policy for updating program collateral.
4. For the following health education topics, please indicate the form of communication
available. Indicate the reading level.
General
Health
OUTSOURCED
SERVICES
Brochures
Posters
Table
Tents
Booklets
Languages
available
(Eng, Span)
Other
VENDOR
Heart Disease
Service
Diabetes
Community
Name of
Offer
Manage
Coordinate
not
Hypertension
Partnership
Vendor
Asthma
offered
Walking programs
Nutrition
Online programs:
Fitness & Exercise
Other:
Other:
MARKETING AND COMMUNICATIONS
Provide samples of a generic communication strategy for our client. Include all aspects,
target audience and roles of account team, including your Wellness Coordinator. Include
creative ideas to promote optimal participation.
2. Do you have standard communication materials that support your programs and services?
If so, are the materials customizable and to what extent?
3. Describe your policy for updating program collateral.
4. For the following health education topics, please indicate the form of communication
available. Indicate the reading level.
Section Four - Wellness Page 6
General
Health
Education Material
Brochures
Posters
Table
Tents
Booklets
Languages
available
(Eng, Span)
Other
Reading
level
Heart Disease
Diabetes
Cholesterol
Hypertension
Asthma
Nutrition
Fitness & Exercise
Women's Health
Men's Health
Self Care
Smoking Cessation
Weight
Management
Section Four - Wellness Page 6
Stress Management
Other:
Other:
Other:
REPORTING
1. Indicate the type of reporting you use to track, analyze and to assess cost savings. How
do you obtain the information for your reports?
2. Describe your participant survey process, to include: distribution frequency, the
anticipated response percentage and delivery modes.
3. Describe the criteria required to have a third party vendor complete a data audit.
4. Provide copies of all standard client reports. Can they be generated online by the client
or by demand? Can both the client and the broker have access to generate and /or review
reports? Can they be customized? If yes, what are the options and associated costs?
Section Four - Wellness Page 7
REPORTS
(Yes/No)
FREQUENCY
Monthly, Quarterly or
Annuall
Enrollment
Participation
Utilization
Health Risk Change
Clinical Outcomes
Participant Satisfaction
Claims Savings
❑ Medical ❑ RX
❑ Diagnosis
Short term Disability
Absenteeism
Productivity
Quality of Life
ROI
Administration
Other:
Other:
2. Describe your participant survey process, to include: distribution frequency, the
anticipated response percentage and delivery modes.
3. Describe the criteria required to have a third party vendor complete a data audit.
4. Provide copies of all standard client reports. Can they be generated online by the client
or by demand? Can both the client and the broker have access to generate and /or review
reports? Can they be customized? If yes, what are the options and associated costs?
Section Four - Wellness Page 7
TECHNOLOGY
1. Describe your current delivery system platform used to support your internet based
programs. Examples: tools used to facilitate the delivery of your programs including data
management, program monitoring, tracking and reporting.
2. Describe your interface capabilities with another vendor's system.
3. Describe your resources to maintain and upgrade current technology. How often do you
upgrade your operating systems?
INTEGRATION
1. Describe each type of vendors with which your program has been integrated (i.e., system
interface /data sharing, care coordination, and referrals, etc.). Please rate the
effectiveness on a scale from 1 — 5 (5 being most effective).
Section Four - Wellness Page 8
TYPE OF INTEGRATION
RATE OF
EFFECTIVENESS
❑ System interface / Data
sharing
1
2
3
4
5
Medical Plans
❑ Coordination of Care
1
2
3
4
5
❑ Referrals
1
2
3
4
5
❑
1
2
3
4
5
Other:
❑ System interface / Data
sharing
1
2
3
4
5
EAP
❑ Coordination of Care
1
2
3
4
5
❑ Referrals
1
2
3
4
5
❑
1
2
3
4
5
Other:
❑ System interface / Data
sharing
1
2
3
4
5
Case Management
❑ Coordination of Care
1
2
3
4
5
❑ Referrals
1
2
3
4
5
❑
1
2
3
4
5
Other:
❑ System interface / Data
sharing
1
2
3
4
5
Disease Management
❑ Coordination of Care
1
2
3
4
5
❑ Referrals
1
2
3
4
5
❑
1
2
3
4
5
Other:
Behavioral Health Care
❑ System interface / Data
1
2
3
4
5
sharing
1 1
2
3
4
5
Section Four - Wellness Page 8
2. Describe how the integration process adds value for your clients.
3. Please confirm your ability and willingness to coordinate activities and share necessary
eligibility and data with outside vendors. If there is any charge for any of these activities,
please identify it clearly in your pricing.
PERFORMANCE GUARANTEES
1. Provide a list of the performance guarantee parameters you use. Can you guarantee ROI?
What guarantees will you provide for MCBCC?
HIPAA
1. Explain your HIPAA policy. Explain how you comply with HIPAA regulations as they
relate to wellness programs.
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four - Wellness Page 9
❑ Coordination of Care
❑ Referrals
Other:
1
1
2
2
3
3
4
4
5
5
❑ System interface / Data
sharing
1
2
3
4
5
❑ Coordination of Care
1
2
3
4
5
Nurse Care Lines
❑ Referrals
1
2
3
4
5
❑
1
2
3
4
5
Other:
❑ System interface / Data
sharing
1
2
3
4
5
❑ Coordination of Care
1
2
3
4
5
Other:
❑ Referrals
1
2
3
4
5
❑
1
2
3
4
5
Other:
2. Describe how the integration process adds value for your clients.
3. Please confirm your ability and willingness to coordinate activities and share necessary
eligibility and data with outside vendors. If there is any charge for any of these activities,
please identify it clearly in your pricing.
PERFORMANCE GUARANTEES
1. Provide a list of the performance guarantee parameters you use. Can you guarantee ROI?
What guarantees will you provide for MCBCC?
HIPAA
1. Explain your HIPAA policy. Explain how you comply with HIPAA regulations as they
relate to wellness programs.
The Representative stated below is the authorized agent of the Proposer and is authorized to bind
the company upon acceptance by the County. Deviations from the requested program have been
stated. Coverage(s) or services will be issued as proposed.
Authorized Representative Print Name Firm Telephone Date
Authorized Representative Signature
Section Four - Wellness Page 9
SECTION FIVE - PRICING
Complete the exhibit by entering the PEPM Cost for each separate component listed. If the component is included in
the overall Administration fee, please indicate. If it is not provided, please indicate such in the cell. Please enter the
total PEPM charge for all services quoted in line 40. Enter your monthly estimated enrollment in line 42.
CLAIMS ADMINISTRATION SERVICES
{Vendor Name}
2011
2012
2013
CLAIMS ADMINISTRATION
Administration Fee
$$$
$$$
$$$
Hospital Bill Audit
$$$
$$$
$$$
Late Entrant Underwriting
$$$
$$$
$$$
Subrogation Services
$$$
$$$
$$$
Repricing Fees
$$$
$$$
$$$
Coordination of Benefits
$$$
$$$
$$$
Grievance /Appeals Administration
$$$
$$$
$$$
External Review Process
$$$
$$$
$$$
Other (State & show PEPM cost)
Other (State & show PEPM cost)
SET UP FEES
Client Set U
$$$
$$$
$$$
Enrollment Assistance
$$$
$$$
$$$
Plan Document - Original
$$$
$$$
$$$
Booklet fee each
$$$
$$$
$$$
Renewal fee if an
$$$
$$$
$$$
ID Cards, Claim Forms, Enrollment Manual, etc.
$$$
$$$
$$$
Other (State & show PEPM cost)
Other (State & show PEPM cost)
OTHER SERVICES
Claim Fiduciary
$$$
$$$
$$$
HIPAA Certificates at termination
$$$
$$$
$$$
COBRA Notifications
$$$
$$$
$$$
Nurse Hotline
$$$
$$$
$$$
Customer Service Line
$$$
$$$
$$$
PBM Interface Fees PEPM
$$$
$$$
$$$
Disease Management Interface Fees
$$$
$$$
$$$
Stop Loss Interface Fees
$$$
$$$
$$$
COBRA / HIPAA
$$$
$$$
$$$
Run -Out Fees
$$$
$$$
$$$
Reporting - monthly
$$$
$$$
$$$
Reporting - Ad Hoc
$$$
$$$
$$$
Other (State & show PEPM cost)
Other (State & show PEPM cost)
TOTAL CLAIMS ADMINISTRATION FEES
PEPM*
Estimated Enrollment:
1621
TOTAL ESTIMATED ANNUAL ADMIN FEES
$0
$0
$0
Performance Guarantees
SECTION FIVE - PRICING
Complete the exhibit by entering your Assumed Enrollment in column B, and enter your all inclusive premium rate for each rate
type specified. Please provide rates for the rate structure shown. If you are proposing a different rate structure, please add
additional Pricing pages, with all contingencies for each quote outlined.
If there are any services that have been requested in the RFP that are NOT included in this rate, please indicate clearly what
those services are and whether you are providing pricing for that service separately.
FULLY INSURED PREMIUM
{Vendor Name}
Assumed 2011 2012 2013
Enrollment
POLICY PROVISION
Specific Pricing
Single
$$$
$$$
$$$
Employee + Spouse
$$$
$$$
$$$
Employee + Child(ren)
$$$
$$$
$$$
Employee + Family
$$$
$$$
$$$
Composite
$$$
$$$
$$$
Please state any contingencies clearly
TOTAL ESTIMATED ANNUAL PREMIUM
#VALUE!
#VALUE!
#VALUE!
Performance Guarantees
State guarantee and amount at risk
SECTION FIVE - PRICING
Complete the exhibit by entering the PEPM Cost for each separate component listed. If the component is
included in the overall Administration fee, please indicate. If it is not provided, please indicate such in the
cell. Please enter your total PEPM price for all services quoted in line 46. Enter your total monthly
estimated enrollment in Line 48.
MEDICAL MANAGEMENT SERVICES
{Vendor Name}
2011
2012
2013
SET UP FEES
Client Set Up
$$$
$$$
$$$
Renewal fee (if any)
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
UTILIZATION MANAGEMENT
Prior Authorization for Advanced Imaging
$$$
$$$
$$$
Hospital Pre - Certification: concurrent and
retrospective review
$$$
$$$
$$$
Focused Out - Patient Review
$$$
$$$
$$$
Large Case Management
$$$
$$$
$$$
Nurse Hotline
$$$
$$$
$$$
Patient Outreach
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
DISEASE MANAGEMENT
Entire Program
$$$
$$$
$$$
Diabetes
$$$
$$$
$$$
Hypertension
$$$
$$$
$$$
CHF
$$$
$$$
$$$
CAD
$$$
$$$
$$$
Asthma / COPD
$$$
$$$
$$$
NICU
$$$
$$$
$$$
Maternity / High Risk Pregnancy
$$$
$$$
$$$
Depression
$$$
$$$
$$$
Rare Diseases
$$$
$$$
$$$
HIV /Aides
$$$
$$$
$$$
Lower Back Pain
$$$
$$$
$$$
Arthritis
$$$
$$$
$$$
Chronic Kidney Disease /ESRD
$$$
$$$
$$$
Patient Outreach
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
OTHER SERVICES
Pharmacy Benefits Manager Interface
$$$
$$$
$$$
Claims Administrator Interface
$$$
$$$
$$$
Stop Loss Interface
$$$
$$$
$$$
Reporting - Routing
$$$
$$$
$$$
Reporting - Ad Hoc
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
TOTAL MEDICAL MANAGEMENT FEES PEPM*
Estimated Enrollment:
1621
TOTAL ESTIMATED ANNUAL ADMIN FEES
$0
$0
$0
Performance Guarantees
State guarantee and amount at risk
SECTION FIVE - PRICING
Complete the exhibit by entering the PEPM Cost for each separate component listed. If the component is included in
the overall Administration fee, please indicate. If it is not provided, please indicate such in the cell. Please enter the
total PEPM pricing for all services quoted in line 26. Please enter your monthly estimated enrollment in line 28.
NETWORK MANAGEMENT
(Vendor Name)
ADMINISTRATIVE FUNCTION
2011
2012
2013
SET UP FEES
Client Set Up
$$$
$$$
$$$
Renewal Fees
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
PPO NETWORK ADMINISTRATION
Access Fee
$$$
$$$
$$$
Network Directories
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
OTHER SERVICES
Claim Re- pricing (if needed)
$$$
$$$
$$$
Reporting - routine
$$$
$$$
$$$
Reporting - ad hoc
$$$
$$$
$$$
Claim Administrator Interface (if needed)
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
TOTAL NETWORK MANAGEMENT FEES
PEPM*
Estimated Enrollment:
1621 0.00
0.00
0.00
TOTAL ESTIMATED ANNUAL ADMIN FEES
$0
$0
$0
Performance Guarantees I State guarantee and amount at risk
SECTION FIVE - PBM PRICING
INSTRUCTIONS FOR VENDOR PRICE OFFER WORKSHEET
1. Use the same file to fill in you answers for both the traditional
and Pass Through plans if applicable. If you are only offering one
of the model types just leave the other blank or state N /A.
2. Fill in all boxes in the work sheet; do not leave any box blank. If
a box does not apply indicate N/A or "does not apply"
3. Do not change the format of the file it must be sent in Microsoft
Excel.
4. All fees should be indicated in dollars. Example 50 cents should
be indicated as $0.50
5. For the rebate answers please indicate if the rebate is per Rx or
per brand Rx, do not use rebateable Rx as we have no way of
knowing what products are "rebateable" in your contracts. Do not
use PEPM or PMPM as those numbers will vary daily.
6. Rebates are to be guaranteed amounts indicate either minimum
or maximum where applicable.
7. Brand discounts are to be indicated as AWP- XX% guaranteed.
8. Please use pre -AWP settlement AWP and post AWP
settlement in your responses, both are required.
9. Generics are to be indicated as AWP -XX %, do not list MAC
and non MAC. The discounts are to be indicated as guaranteed
discounts off AWP for all generic RX (total generic Rx count)
(Shortfalls on the guaranteed discounts cannot be offset by
overages on any other discount guarantee.
10. All average discount questions are to be answered with book of
business averagesfor your commercial accounts (no medicare or
medicaid)
11. The work sheet must be submitted as a Microsoft excel
spreadsheet and each box will need to have wrap around text so
all answers can be seen in their entirety.
12. All comments are to be placed in the comments column do not
list with your answer.
13. Please read the questions carefully as they may ask for more
than one answer. You must answer all parts of the question.
Prospective PBM VENDOR Price
The purpose of this document is to gather information concerning a PBM's price offerings for an RFP process (Use Pre and Post AWP
settlement numbers when requested)
.'
MCBOCC MCBOCC
Traditional
Pass Through
Comments
Number of pharmacies in network
Number of Pharmacies in closed
network and pricin
Number of pharmacies in custom
network and pricin
Retail paid claim administration fee or
Total administration fee. This is what you
charge per Rx for all basic PBM
services. If listed PEPM or PMPM you
should also convert to per Rx based on
Rx count.
Mail Service paid claim administration
fee (same parameters as retail see
above
Retail rejected claim administration fee
Mail Service rejected claim
administration fee
Member submitted claim administration
fee. List by Uncomplicated /Complicated,
if applicable.
Retail claim reversal administrative fee
Mail Service claim reversal
administrative fee
Retail 2 -tier per claim rebate by brand
Rx guaranteed
Retail 2 -tier per claim rebate by all
claims guaranteed
Mail Service 2 -tier per claim rebate by
claim guaranteed Indicate minimum or
maximum
Mail Service 2 -tier per claim rebate by
brand claim guaranteed Indicate
minimum or maximum
90 day at retail 2 -tier per claim rebate.
Indicate minimum or maximum
Retail 3 -tier per claim rebate /$15
differential. Indicate minimum or
maximum
Mail Service 3 -tier per claim rebate /$30
differential. Indicate minimum or
maximum
90 day at retail 3 -tier per claim rebate.
Indicate minimum or maximum
Are all rebates guaranteed? Minimum or
maximum?
Rebate administration fee? Rebate
guarantees above must be after any
rebate admin fee is extracted.
Retail brand discount guaranteed AWP -
XX% format Pre and Post AWP
settlement numbers for every request
Retail dispensing fee guaranteed
( brand/ generic
Retail generic discount (guaranteed)
AWP -XX% format (do not list MAC
guarantee, just total blended guarantee.
90 day at Retail brand discount
guaranteed pre and post AWP
settlement numbers
90 day at retail generic discount
(guarantee) (do not list MAC guarantee,
just total blended guarantee.
90 day at retail dispensing fee
g uaranteed brand/ generic
MAC affect at retail
MAC affect at mail
% of generics MAC'd at retail give total
GPI or GCN number of generics that are
MAC'd divided by total number of GPI or
GCN codes available. Please show
number of GCN or GPI's on your MAC
List and the total GCN or GPI's available.
% of generics MAC'd at mail give total
GPI or GCN number of generics that are
MAC'd divided by total number of GPI or
GCN codes available. Please show
number of GCN or GPI on your Mail
MAC List and the total number of GCN
or GPI's available.
Does "lower of usual and customary
(U &C)" pricing always apply at retail?
Explain the $4 Rx and how it adjudicates
What is your average generic discount
off AWP for your entire book of
commercial business - Retail and Mail
What is the expected overall generic
discount for this client when excluding
U &C and zero balance claims at retail?
Is there a price differential between the
amount billed to the plan sponsor and
the amount paid to the pharmacy for
brand dru s? (Spread) Neg or Pos
Is there a price differential between the
amount billed to the plan sponsor and
the amount paid to the pharmacy for
eneric drugs? (Spread) neg or Pos
Mail Service brand discount guaranteed
pre and post AWP settlement numbers
Mail Service dispensing fee guaranteed
( Brand/ generic
Mail Service generic discount
(guaranteed). Do not list MAC
guarantee, just total blended guarantee.
Administrative fee Retail claim
brand/ generic guaranteed
Administrative fee 90 day at retail
brand/ generic guaranteed
Administrative fee mail service
brand/ generic guaranteed
What Is MAC pricing offered on Mail
service? If not why?
If yes, is the mail service MAC the same
as the retail MAC?
What services are included with the
basic fee
Is Concurrent DUR Included or fee. Give
fee
Standard retrospective DUR included or
fee. Give fee
Substance Abuse Programs- Fee?
Quantity Limit Programs- Fee?
Disease management programs
included or fee. Give fee by DSM
p rogram
Name all Disease Management
programs you have to offer and their
associated fees
Trend management programs included
or fee
Name all trend management programs
offered with their associated fees
Administrative prior authorizations
included or fee. List fees
Clinical prior authorizations included or
fee. List fees
Electronic eligibility submission
available?
Access to on -line eligibility system (who
and how many ports available?
Manual (hardcopy) eligibility submission
fee
Standard reports (printed, CD or internet
access )fee
List fees for ad hoc orspecial reports
Employer Website with Rx information
and online refill ordering available? List
URL.
Software provided for on -line report
system included or fee
Training for on -line report system
included or fee
Ad Hoc report requests/ cost per hour
How many ID Cards are included in
standard/ additional card or replacement
card costs
Pharmacy directories online and printed?
What other materials to members and
fees?
Member website with health information
and my Rx space available? List URL.
List implementation fees or credits
available and explain if consultant fees
can be paid from this allowance and how
they are paid.
Do you own your own specialty
p harmacy List name and locations
List specialty pharmacy that would
handle this client
Average Retail Discount on Network
Specialty Pharmacy Brand products
g uaranteed
Average Retail Discount on Network
Specialty Pharmacy generic products
uaranteed
Average Mail Discount on Specialty
Pharmacy Brand products guaranteed
Average Mail Discount on Specialty
Pharmacy generic products guaranteed
Average 90 day at retail Discount on
Specialty Pharmacy brand products
,g uaranteed
Average 90 day at retail Discount on
Specialty Pharmacy generic products
g uaranteed
Specialty pharmacy exclusive program
brand discounts guaranteed
Specialty pharmacy exclusive program
generic discounts guaranteed
Specialty Pharmacy Dispensing Fee -
Retail brand guaranteed
Specialty Pharmacy Dispensing Fee -
Retail generic guaranteed
Specialty Pharmacy Dispensing Fee - 90
day at Retail brand guaranteed
Specialty Pharmacy Dispensing Fee - 90
day at Retail generic guaranteed
Exclusive Specialty Pharmacy
Dispensing Fee - Brand guaranteed
Exclusive Specialty Pharmacy
Dispensing Fee - generic guaranteed
Specialty Pharmacy Dispensing Fee -
Mail generic guaranteed
Specialty Pharmacy Dispensing Fee -
Mail Brand guaranteed
Specialty Pharmacy Administrative Fee -
retail brand
Specialty Pharmacy Administrative Fee -
retail generic
Specialty Pharmacy Administrative Fee -
Mail brand
Specialty Pharmacy Administrative Fee -
Mail generic
Exclusive Specialty Pharmacy
Administrative Fee- Brand
Exclusive Specialty Pharmacy
Administrative Fee- generic
Generic fill rate guaranteed- retail
Generic fill rate guaranteed- mail
What is your average Generic fill rate for
your entire book of commercial business
in retail ? (required!
What is your average Generic fill rate for
your entire book of commercial business
in mail ? re uired!
What is your average Generic fill rate for
your entire book of commercial business
combined mail and retail? (required!)
SECTION FIVE - PRICING
Complete the exhibit by entering the PEPM Cost for your quotes for each of the options requested. Please enter your assumed
enrollment for each rate type and use this in determining your estimated annual premium costs. Enter your monthly estimated
enrollment in A 37
STOP LOSS INSURANCE
Assumed
Enrollment
{Vendor Name}
POLICY PROVISION
Option 1
Option 2
Option 3
Specific Stop Loss
Specific Deductible
$175,000
$225,000
$250,000
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Policy Term
15/12
15/12
15/12
Specific Pricing
Single
$$$
$$$
$$$
Employee + Spouse
$$$
$$$
$$$
Employee + Child(ren)
$$$
$$$
$$$
Employee + Family
$$$
$$$
$$$
Composite
$$$
$$$
$$$
Aggregate Stop Loss
Corridor
125%
125%
125%
Annual Maximum
Unlimited
Unlimited
Unlimited
Policy Term
15/12
15/12
15/12
Aggregate Pricing
Single
$$$
$$$
$$$
Employee + Spouse
$$$
$$$
$$$
Employee + Child(ren)
$$$
$$$
$$$
Employee + Family
$$$
$$$
$$$
Composite
$$$
$$$
$$$
Aggregate Factor
Composite
$$$
$$$
$$$
Annual Attachment Factor
$$$
$$$
$$$
Total PEPM Stop Loss Premium 0.00
0.00
0.00
Estimated Enrollment:
1621
TOTAL ESTIMATED ANNUAL PREMIUM
COSTS
$0
$0
$0
Performance Guarantees
State guarantee and amount at risk
SECTION FIVE - PRICING
Complete the exhibit by entering the PEPM Cost for each separate component listed. If the component is included in
the overall Base fee, please indicate. If it is not provided, please indicate such in the cell.
If your PEPM fees are based on participation assumptions, please clearly outline them on a separate page and modify
the "Total Estimated Annual Fees" to reflect your estimate.
WELLNESS PROGRAMS
(Vendor Name)
ADMINISTRATIVE FUNCTION
2011
2012
2013
SET UP FEES
Client Set U
$$$
$$$
$$$
Renewal Fees
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
Wellness Programs
Base Fee
$$$
$$$
$$$
Biometric Screenings
$$$
$$$
$$$
Health Risk Assessments (HRA's)
$$$
$$$
$$$
Health Fairs
$$$
$$$
$$$
Incentive Administration
$$$
$$$
$$$
Other State & show PEPM cost
$$$
$$$
$$$
Web /Phone Based Programs
Weight loss - Nutrition
$$$
$$$
$$$
Walking
$$$
$$$
$$$
Stress Reduction
$$$
$$$
$$$
Smoking Cessation
$$$
$$$
$$$
Physical Activity
$$$
$$$
$$$
Health Coaching one - one
$$$
$$$
$$$
Other (State & show PEPM cost)
$$$
$$$
$$$
On -Site Components Offered
Weight loss - Nutrition
$$$
$$$
$$$
Walking
$$$
$$$
$$$
Stress Reduction
$$$
$$$
$$$
Smoking Cessation
$$$
$$$
$$$
Physical Activity
$$$
$$$
$$$
On -Site Coordinator
$$$
$$$
$$$
Other State & show PEPM cost
$$$
$$$
$$$
Reporting
Quarterly and Annual Participation & ROI
$$$
$$$
$$$
Ad hoc Reports
$$$
$$$
$$$
TOTAL WELLNESS FEES PEPM **
Estimated Enrollment:
1621 0.00
0.00
0.00
TOTAL ESTIMATED ANNUAL FEES
$0
$0
$0
Performance Guarantees
State guarantee and amount at risk