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Blue Options Benefit Booklet • AMY HEAVILIH, CPA K.........._ CLERK OF CIRCUIT COURT & COMPTROLLER � �. I �j� MORRDE CDUNTZ FLDRIDA DATE: April28, 2016 TO: Theresa Aguiar, Division Director of Employee Services ATTN: Maria Gonzalez FROM: Cheryl Robertson Executive Aide to the Clerk of Court& Comptroller C g. At the October 21, 2015 Board of County Commissioner's meeting the Board granted approval of Item D4 Approval of the 2015 Blue Options Benefit Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan(a.k.a. Plan Document). Attached is a copy of the 2015 Blue Options Benefit Booklet. Should you have any questions, please feel free to contact me. Nhiteheod Street Suite 101,PO Box 1980,Key West,FL 33040 Phone:305-295-3130 Fax:305-295-3663 3117 Overseas Highway,Marathon,FL 33050 Phone:305-289-6027 Fax:305-289-6025 88820 Overseas Highway,Plantation Key,FL 33070 Phone:852-7145 Fax:305-852-7146 BlueOptions Benefit Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan A Self-funded Group Health Benefit Plan For Customer Service Assistance: (800) 664-5295 00511-aa1N IpiaR01 n 0]55 C GMskroO01,COt, ,RO2.W2 Table of Contents Section 1: How to Use Your Benefit Booklet 1-1 Section 2: What Is Covered? 2-1 Section 3: What Is Not Covered? 3-1 Section 4: Medical Necessity .. 4-1 Section 5: Understanding Your Share of Health Care Expenses 5-1 Section 6: Physicians, Hospitals and Other Provider Options 6-1 Section 7: BlueCard°(Out-of-State)Program 7-1 Section 8: Blueprint for Health Programs 8-1 Section 9:- Eligibility for Coverage 9-1 Section 10: Enrollment and Effective Date of Coverage 10-1 Section 11: Termination of Coverage 11-1 Section 12: Continuing Coverage Under COBRA 12-1 Section 13: Conversion Privilege........._.......... 13.1 Section 14: Extension of Benefits 14.1 Section 15: The Effect of Medicare Coverage/Medicare Secondary Payer Provisions 15-1 Section 16: Duplication of Coverage Under Other Health Plans/Programs 16-1 Section 17: Subrogation 17-1 Section 18: Right of Reimbursement 18-1 Section 19: Claims Processing 19-1 Section 20: Relationship Between the Parties 20-1 Section 21: General Provisions 21-1 Section 22: Definitions 22-1 r.m.aeorx.ro Section 1 : How to Use Your Benefit Booklet This Is your Benefit Booklet("BookieP). It be coordinated with other policies or plans; describes your coverage, benefits, limitations and the Group Health Plan's subrogation and exclusions for the self-funded Group Health rights and right of reimbursement. Benefit Plan("Group Health Plan"or"Group You will need to refer to the Schedule of Plan")established and maintained by Monroe Benefits to determine how much you have to County BOCC. pay for particular Health Care Services. The sponsor of your Group Health Plan has contracted with Blue Cross Blue Shield of When reading your Booklet, please Florida,Inc.(BCBSF), under an Administrative remember that: Services Only Agreement("ASO Agreement"), • you should read this Booklet in its entirety In to provide certain third party administrative order to determine If a particular Health Care services,including claims processing,customer Service is covered. service,and other services,and access to certain of its Provider networks. BCBSF • the headings of sections contained in this provides certain administrative services only and Booklet are for reference purposes only and does not assume any financial risk or obligation shall not affect In any way the meaning or with respect to Health Care Services rendered to interpretation of particular provisions. Covered Persons or claims submitted for • references to"you'or"your"throughout refer processing under this Benefit Booklet for such to you as the Covered Plan Participant and to Services.The payment of claims under the your Covered Dependents, unless expressly Group Health Plan depends exclusively upon staled otherwise or unless,in the context in the funding provided by Monroe County BOCC. which the term Is used,it is clearly intended You should read your Benefit Booklet carefully otherwise. Any references which refer solely before you need Health Care Services. It to you as the Covered Plan Participant or contains valuable information about: solely to your Covered Dependent(s)will be noted as such. • your BlueOptions benefits; • references to"we","us',and'our"throughout • what is covered; refer to Blue Cross and Blue Shield of • what is excluded or not covered; Florida, Inc. We may also refer to ourselves • coverage and payment rules; as"BCBSF". • Blueprint for Health Programs; • If a word or phrase starts with a capital letter, it is either the first word in a sentence,a • how and when to file a claim; proper name,a title,or a defined term. If the • how much,and under what circumstances, word or phrase has a special meaning, it will payment will be made; either be defined in the Definitions section or defined within the particular section where it • what you will have to pay as your share;and Is used. • other important Information including when benefits may change;how and when coverage stops; how to continue coverage If you are no longer eligible;how benefits will Mowm Use Yaw Boreal Booklet 1.1 Where do you find information on • what particular types of Health Care • how to add or remove a Dependent? Services are covered? Read the"Enrollment and Effective Date of Read the-What is Covered?'and"What Is Coverage'section. Not Covered?'sections. • what happens if you are covered under • how much will be paid under your Group this Benefit Booklet and another health Health Plan and how much do you have to plan? pay? Read the"Duplication of Coverage Under Read the'Understandng Your Share of Other Health Plans Programs'section. Health Care Expenses'section along with the • what happens when your coverage ends? Schedule of Benefits. how the amountyou Read the"Termination of Coverage"section. • pay for Covered Services under the BlueCard (Out-of- • what the terms used throughout this State)Program will be determined when Booklet mean? you receive care outside the state of Read the'Definitions'section. Florida? Read the'BlueCard(Out-of-State)Program" section. Overview of How BlueOptions Works Whenever you need care,you have a choice. If you visit an: In-Network Provider Out-of-Network Provider You receive In-Network benefits,the You receive the Out-of-Network level of highest level of coverage available. benefits—you will share more of the cost of your care. You do not have to file a claim;the claim You may be required to submit a claim form. will be filed by the In-Network Provider for you. The In-Network Provider'is responsible You should notify BCBSF of inpatient for Admission Notification if you ere admissions. admitted to the Hospital. 'For Services rendered by an In-Network Provider located outside of Florida,you should nobly us of inpatient admissions. lbw WVw Your Bondi aoowbl 1-2 Section 2: What Is Covered? Introduction Necessity coverage criteria then In effect, except as specified ki this section; This section describes the Health Care Services that are covered under this Benefit Booklet. All 4. in accordance with the benefit guidelines benefits for Covered Services are subject to listed below; your share of the cost and the benefit 5. rendered while your coverage is in force; maximums listed on your Schedule of Benefits, and the applicable Allowed Amount, any limitations 6. not specifically or generally limited or andlor exclusions,as well as other provisions excluded under this Booklet. contained in this Booklet,and any Endorsement(s)In accordance with BCBSF's BCBSF or Monroe County BOCC will determine Medical Necessity coverage criteria and benefit whether Services are Covered Services under guidelines then in effect. this Booklet after you have obtained the Services and a claim has been received for the Remember that exclusions and limitations also Services. In some circumstances BCBSF or apply to your coverage. Exclusions and Monroe County BOCC may determine whether limitations that are specific to a type of Service Services might be Covered Services under this are inciuded along with the benefit description in Booklet before you are provided the Service. this section. Additional exclusions and For example, BCBSF or Monroe County BOCC limitations that may apply can be found in the may determine whether a proposed transplant is "What Is Not Covered?section. More than one a Covered Service under this Booklet before the fimitauon or exclusion may apply to a specific transplant is provided. Neither BCBSF nor Service or a particular situation. Monroe County BOCC are obligated to Expenses for the Health Care Services listed In determine,in advance,whether any Service not this section will be covered under this Booklet yet provided to you would be a Covered Service only if the Services are: unless we have specifically designated that a Service Is subject to a prior authorization 1. within the Health Care Services categories requirement as described in the"Blueprint for in the"What is Covered?"section; Health Programs"section. We are also not 2. actually rendered(not just proposed or obligated to cover or pay for any Service that recommended)by an appropriately licensed has not actually been rendered to you. health care Provider who is recognized for in determining whether Health Care Services payment under this Benefit Booklet and for are Covered Services under this Booklet,no which an itemized statement or description written or verbal representation by any of the procedure or Service which was employee or agent of BCBSF or Monroe County rendered is received,including any BOCC,or by any other person,shall waive or applicable procedure code,diagnosis code otherwise modify the terms of this Booklet and, and other information required in order to therefore,neither you,nor any health care process a claim for the Service; Provider or other person should rely on any such 3. Medically Necessary,as defined In this written or verbal representation. Booklet and determined by BCBSF in accordance with BCBSF's Medical What b Covered? 2-r Our Benefit Guidelines number of tests performed by the Physician. The Allowed Amount for allergy immunotherapy In providing benefits for Covered Services,the treatment Is based upon the type end number of benefit guidelines listed below apply as well as doses. any other applicable payment rules specific to particular categories of Services: Ambulance Services 1. Payment for certain Health Care Services is Ambulance Services provided by a ground included within the Allowed Amount for the vehicle may be covered provided it is necessary primary procedure,and therefore no to transport you from: additional amount Is payable for any such 1, a Hospital which is unable to provide proper Services. care to the nearest Hospital that can provide 2. Payment Is based on the Allowed Amount proper care; for the actual Service rendered(I.e., 2. a Hospital to your nearest home,or to a payment is not based on the Allowed Skilled Nursing Facility;or Amount for a Service which is more complex than that actually rendered),and Is not 3. the place a medical emergency occurs to based on the method utilized to perform the the nearest Hospital that can provide proper Service or the day of the week or the time of care. day the procedure is performed. Expenses for Ambulance Services by boat, 3. Payment for a Service Includes all airplane,or helicopter shall be limited to the components of the Health Care Service Allowed Amount for a ground vehicle unless: when the Service can be described by a 1. the pick-up point Is inaccessible by ground -- -single procedure code,or when the Service vehicle; is an essential or integral part of the associated therapeutic/diagnostic Service 2. speed in excess of ground vehicle speed Is rendered. critical;or 3. the travel distance involved in getting you to Covered Services Categories the nearest Hospital that can provide proper care is too far for medical safety,as Accident Care determined by SCBSF or Monroe County Health Care Services to treat an Injury or illness BOCC. resulting from an Accident not related to your Job pyeaceref or employment are covered. per-daymaxlmurne fer-greund transpeAoNen Exclusion: Health Care Services to treat an injury or Illness Ambulatory Surgical Centers resulting from an Accident related to your job or employment are excluded. Health Care Services rendered at an Ambulatory Surgical Center are covered and include: Allergy Testing and Treatments 1. use of operating and recovery rooms; Testing and desensitization therapy(e.g., 2. respiratory,or inhalation therapy(e.g ., injections)and the cost of hyposensiazalion oxygen); serum are covered. The Allowed Amount for allergy testing Is based upon the type and What le Covered? 2-2 3. drugs and medicines administered(except 1. well-baby and well-child screening for the for lake home drugs)at the Ambulatory presence of Autism Spectrum Disorder; Surgical Center; 2. Applied Behavior Analysis,when rendered 4. intravenous solutions; by an individual certified pursuant to Section 8. dressings, Including ordinary casts; 393.17 of the Florida Statutes or licensed under Chapters 490 or 491 of the Flanda B. anesthetics and their administration; Statutes;and 7. administration of,Including the cost of, 3. Physical Therapy by a Physical Therapist, whole blood or blood products(except as Occupational Therapy by an Occupational outlined in the Drugs exclusion of the'What Therapist,and Speech Therapy by a Is Not Covered?section); Speech Therapist. Covered therapies 8. transfusion supplies and equipment; provided In the treatment of Autism 9. diagnostic Services, Including radiology, Spectrum Disorder are covered even though ultrasound, laboratory,pathology and they may be habilllalive In nature(provided approved machine testing(e.g., EKG);and to teach a function)and are not necessarily limited to restoration of a function or skill that 10. chemotherapy treatment for proven has been lost. malignant disease. Payment Guidelines for Autism Spectrum Anesthesia Administration Services Disorder Administration of anesthesia by a Physician or The covered therapies provided in the treatment Certified Registered Nurse Anesthetist('CRNA') of Autism Spectrum Disorder outlined in may-be-covered. In those instances where the paragraph three above will be applied to the CRNA is actively directed by a Physician other Outpatient Therapies Benefit Period maximum than the Physician who performed the surgical set forth in the Schedule of Benefits.Autism procedure,payment for Covered Services,if Spectrum Disorder Services must be authorized any,will be made for both the CRNA and the In accordance with BCBSF's established criteria, Physician Health Care Services at the lower before such Services are rendered. Services directed-services Allowed Amount in accordance performed without authorization will be denied. with BCBSF's payment program then in effect Authorization for coverage is not required when for such Covered Services. Covered Services are provided for the treatment of an Emergency Medical Condition. Exclusion: Exclusion: Coverage does not include anesthesia Services by an operating Physician, his or her partner or Any Services for the treatment of Autism associate. Spectrum Disorder other than as specifically Identified as covered in this section. Autism Spectrum Disorder Note: In order to determine whether such Autism Spectrum Disorder Services provided to Autism Spectrum Disorder Services are covered a Covered Dependent who is under the age of under this Benefit Booklet,we reserve the right 18,or if 18 years of age or older,is attending to request a formal written treatment plan signed high school and was diagnosed with Autism by the treating Physician to Include the Spectrum Disorder prior to his or her 9th birthday diagnosis,the proposed treatment type,the consisting of: frequency and duration of treatment,the What It Covered? t3 anticipated outcomes stated as goals,and the 6—Saryices for pre-marital counseling' frequency with which the treatment plan will be Z. Sety)cesJpr cogrkordered.eare-ottesting.cr updated,but no less than every 6 months.-This feoulred as a pondilioaof parole or benefit booklet will only cover services to the prpbaijpn; extent included in the Treating Physician's formal written treatment plan. 8. Services to lest aptitude,ability. Intelligence or interest except as covered under the Behavioral Health Services Autism Spectrum Disorder subsection• Mental Health SeLyice$ 4, Services required to maintain employment. 4eeeosuc eyak aticn.psychiatricJrealment 10. Services for cognitive remediation: and Indtydu$JharapY..and grotto therapylandered to you by a Physician.Psveholocist or Mental 11. inpatient(overnight)menial health Services Health ProfessionaLfrirlbakatatment or r Mental received in a residential treatment facility and lamas ,Disorder may ha enyered except when authorized by BCBSF. (lowered Sery ce=_mav'nclude: Substance Dependency Treatment Services 7 Phvsclan offce yisitS When there is a sudden drop in consumption 2. Intensive Ou client Treatment frend&ed• after prolonged heavy use of a substance a ii facility).as defined in this Booklet; person may experience withdrawal,often causing both physiologic and cognitive 3, Partial Hospitalization as defined in this symptoms. The symptoms of withdrawal vary Booldet,when provided under the direction greatly. ranging from minimal changes to of a Physician:and potentially life threatening stales. Detoxification 4. Residential Treatment Services,as defined Services can be rendered in different types of in this Booklet. locations.depending on the severity of the Exclusion withdrawal symptoms. 1 Services rendered for d Condition that is notCare and treatment for Substance Dependency a-MentaLand Nervous Disorder as defined to includes the follewinm iUitBBokieUegardlass of the_underlying 1. Inpatient and outpatient Health Care cause or effect.dine dlsefdar; Services rendered by a Physician 2 Sery''ces.fpr nsolop'ssl lesijpg Psychologist or Mental Health Professional assn algid wlih the evaluado.^^.and diapnosis in a program accredited by The Joint pf leaminn d'sab'Ihies or intellectual Commission or approved by the stale of Florida for Detoxification or Substance djsabilily. Dependency. 0 Services beyond the period.necessary for 2. Physician Psvcholoo'stgndMental Heath - -€ imeticn and diagnosis of leaminn dj,:abflil'e=or intelixt ml dleabWly' protessjonal outpatient yfejta.for Iho rare and treatment of Substance Dependency, 4, Services for educational purposes- We may provide you with information on r5 Services for man'aga-figgnsel'na unless resources available to you for non-medical related to a Mental and Nelygus Disorder as ancillary services like vocational rehabilitation or dafined in thi Booklet. died ss of the employment counseling,when we are able to. undeflying.cause.or effect...of the.disorder: We don't pay for any services that are provided Whae0o.mre07 2-I )o you by any or these resources:they are to be furnished in connection with your participation in gtovlded solely at your expense. You the Approved Clinical Trial may be covered pcknowledae that we do not have any when: Contractual or other formal amanaemenls with 1. an In-Network Provider has indicated such the Provider of such services. trial is appropriate for you;or gxelusion 2. you provide us with medical and scientific Fxnenses fnr innatient confinements that are information establishing that your primarily Intended as a chance of environment participation In such trial Is appropriate. pre excluded. Routine patient care includes all Medically Breast Reconstructive Surgery Necessary Services that would otherwise be Surgery to reestablish symmetry between two covered under this Booklet,such as doctor breasts and implanted prostheses incident to visits,lab tests,x-rays and scans and hospital Mastectomy is covered. In order to be covered, stays related to treatment of your Condition and such surgery must be provided in a manner Is subject to the applicable Cost Share(s)on the chosen by your Physician,consistent with Schedule of Benefits. prevailing medical standards,and In consultation Even though benefits may be available under with you. this Booklet for routine patient care related to an Child Cleft Lip and Cleft Palate Treatment Approved Clinical Trial you may not be eligible for Inclusion In these trials or there may not be Treatment and Services for Child Cleft Lip and any trials available to treat your Condition at the Cleft Palate,Including medical,dental,Speech time you want to be Included in a clinical trial. Therapy,audiology,and nutrition Services for treatment of a child under the age of 18 who has Exclusion_ cleft lip or cleft palate are covered. In order for 1. Costs that are generally covered by the such Services to be covered,your Covered clinical trial,including,but not limited to: Dependent's Physician must specifically prescribe such Services and such Services must a. Research costs related to conducting be medically necessary and consequent to the clinical trial such as research treatment of the cleft lip or cleft palate. Physician and nurse time,analysis of results,and clinical tests performed only Clinical Trials for research purposes. Clinical trials are research studies in which b. The Investigational item, device or Physicians and other researchers work to find Service Itself. ways to improve care. Each study tries to c. Services inconsistent with widely answer scientific questions and to find better accepted and established standards of ways-toprevent,diagnose,or treat patients. care for a particular diagnosis. Each trial has a protocol which explains the I purpose of the trial,how the trial will be 2. Services related to an Approved Clinical performed,who may participate in the trial,and Trial received outside of the United States. the beginning and end points of the trial. Concurrent Physician Care If you are eligible to participate in an Approved Concurrent Physician care Services are Clinical Trial, routine patient care for Services covered, provided: (a)the additional Physician What Is Covered? - 2.5 actively participates in your treatment;(b)the patient management in the dental Condition Involves more than one body system office has proven to be ineffective; or Is so severe or complex that one Physician or cannot provide the care unassisted;and(a)the b) you or your Covered Dependent have Physicians have different specialties or have the same specialty with different sub-specialties. one or more medical Conditions that would create significant or undue Consultations medical risk for you in the course of delivery of any necessary dental Consultations provided by a Physician are covered if your attending Physician requests the treatment or surgery if not rendered in a consultation and the consulting Physician Hospital or Ambulatory Surgical Center. prepares a written report. gxcluslom Contraceptive injections 1. Dental Services provided more than 90 days after the date of an Accidental Dental Injury Medication by Injection Is covered when regardless of whether or not such services provided and administered by a Physician,for could have been rendered within 90 days; the purpose of contraception,and is limited to and the medication and administration when medically necessary. 2. Dental Implant. Dental Services Diabetes Outpatient Self-Management Dental Services are limited to the following: Diabetes outpatient self-management training 1. Care and stabilization treatment rendered and educational Services and nutrition — within 90 days of an Accidental Dental Injury counseling(including all Medically Necessary to Sound Natural Teeth. equipment and supplies)to treat diabetes, if I 2. Extraction of teeth required prior to radiation your treating Physician or a Physician who therapy when you have a diagnosis of specializes in the treatment of diabetes certifies cancer or the head and/or neck. that such Services are Medically Necessary,are covered. In order to be covered,diabetes 3. Anesthesia Services for dental care outpatient self-management training and including general anesthesia and educational Services must be provided under hospitalization Services necessary to assure the direct supervision of a certified Diabetes the safe delvery of necessary dental care Educator or a board-certified Physician provided to you or your Covered Dependent specializing in endocrinology. Additionally,in in a Hospital or Ambulatory Surgical Center order to be covered,nutrition counseling must if: be provided by a licensed Dietitian. Covered I a) the Covered Dependent is under 8 Services may also include the trimming of years of age and it is determined by a toenails,corns,calluses,and therapeutic shoes '--dentist and the Covered Dependent's (including inserts and/or modifications)for the Physician that: treatment of severe diabetic foot disease. I. dental treatment is necessary due to Diagnostic Services a dental Condition that is significantly complex;or Diagnostic Services when ordered by a Physician are limited to the following: N. the Covered Dependent has a developmental disability in which 1. radiology,ultrasound and nuclear medicine, Magnetic Resonance imaging(MRI); What le Coverer? 2E 2. laboratory and pathology Services: wheelchairs,crutches,canes,walkers,hospital 3. Services involving bones or joints of the jaw beds,and oxygen equipment. (e.g..Services to treat temporomandibular Note: Repair or replacement of Durable Joint[TMJ]dysfunction)or facial region if, Medical Equipment due to growth of a child or under accepted medical standards, such significant change in functional status is a diagnostic Services are necessary to treat Covered Service. Conditions caused by congenital or Exclusion: developmental deformity, disease,or injury; Equipment which is primarily for convenience 4. approved machine testing(e.g., and/or comfort;modifications to motor vehicles electrocardiogram [EKG], and/or homes,Including but not limited to, electroencephalograph[EEG],and other wheelchair lifts or ramps;wafer therapy devices electronic diagnostic medical procedures); such as Jacuzzis, hot tubs,swimming pools or and whirlpools;exercise and massage equipment, 5. genetic testing for the purposes of electric scooters,hearing aids,air conditioners explaining current signs and symptoms of a and purifiers, humidifiers,water softeners and/or possible hereditary disease. purifiers,pillows,mattresses or waterbeds, escalators,elevators,stair glides,emergency Dialysis Services alert equipment,handrails and grab bars,heat appliances,dehumidifiers,and the replacement Dialysis Services including equipment,training, of Durable Medical Equipment solely because it and medical supplies,when provided at any is old or used are excluded. location by a Provider licensed to perform III dialysis Including a Dialysis Center are covered. Emergency Services u Durable Medical Equipment Emergency Services for an Emergency Medical Condition are covered when rendered In- Durable Medical Equipment when provided by a Network and Out-of-Network without the need Durable Medical Equipment Provider and when for any prior authorization determination by us. prescribed by a Physician,limited to the most cost-effective equipment as determined by When Emergency Services and care for an BCBSF or Monroe County BOCC Is covered. Emergency Medical Condition are rendered by an Out-of-Network Provider,any Copayment Payment Guidelines for Durabte Medical andfor Coinsurance amount applicable to In- Equloment Network Providers for Emergency Services will Supplies and service to repair medical also apply to such Out-of-Network Provider. equipment may be Covered Services only if you Special Pavment Rules for Non-Grandfathered own the equipment or you are purchasing the Plans equipment. Payment for Durable Medical Equipment will be based on the lowest of the The Patient Protection and Affordable Care Act following: 1)the purchase price;2)the (PPACA)requires that non-grandfathered health lease/purchase price;3)the rental rate;or 4)the plans apply a specific method for determining Allowed Amount. The Mowed Amount for such the allowed amount for Emergency Services rental equipment will not exceed the total rendered for an Emergency Medical Condition purchase price. Durable Medical Equipment by Providers who do not have a contract with us. includes,but is not limited to,the following: Whit la Covered? ].x Payment for Emergency Services rendered by trauma or prior ophthalmic surgery;eye an Out-of-Network Provider that has not entered examinations;eye exercises or visual training; into an agreement with BCBSF to provide eye glasses and contact lenses and their fitting access to a discount from the billed amount of are excluded. In addition to the above,any that Provider will be the greater of: surgical procedure performed primarily to correct or improve myopia or other refractive disorders 1. the amount equal to the median amount (e.g., radial keratotomy,PRK and LASIK)are negotiated with an BCBSF In-Network excluded. Providers for the same Services; 2. the Mowed Amount as defined in the Home Health Care Booklet;or The Home Health Care Services listed below 3. what Medicare would have paid for the are covered when the following criteria are met: Services rendered. 1. you are unable to leave your home without In no event will Out-of-Network Providers be considerable effort and the assistance of paid more than their charges for the Services another person because you are: bedridden rendered. or chairbound or because you are restricted in ambulation whether or not you use Enteral Formulas as&stive devices:or you are significantly Prescription and non-prescription enteral limited in physical activities due to a formulas for home use when prescribed by a Conditign;and Physician as necessary to treat Inherited 2. the Home Health Care Services rendered diseases of amino acid,organic acid, have been prescribed by a Physician by way carbohydrate or fat metabolism as well as of a formal written treatment plan that has malabsorption originating from congenital been reviewed and renewed by the defects present at birth or acquired during the prescribing Physician every 30 days. In neonatal period are covered. order to determine whether such Services Coverage to treat inherited diseases of amino are covered under this Booklet,you may be acid and organic acids,for you up to your 25th required to provide a copy of any written birthday, shall include coverage for food treatment plan; I products modified to be low protein. 3. the Home Health Care Services are provided directly by(or indirectly through)a Eye Care Home Health Agency;and I Coverage Includes the following Services: 4. you are meeting or achieving the desired 1. Physician Services,soft lenses or sclera treatment goals set forth In the treatment shells. for the treatment of aphakic patients; plan as documented in the clinical progress notes. 2. Initial glasses or contact lenses following Home Health Care Services are limited to: cataract surgery;and 1. part-time(I.e.,less than 8 hours per day and 3. Physician Services to treat an injury to or less than a total of 40 hours in a calendar disease of the eyes. week)or intermittent(i.e., a visit of up to,but gxclusion: not exceeding,2 hours per day)nursing cad Li d Health Care Services to diagnose or treat vision Practicalae by Nursested Nurse,omhealth aide and/or home health aide problems which are not a direct consequence of Services; Whit le Coveted? 2-8 2. home health aide Services must be Hospital Services consistent with the plan of treatment, Covered Hospital Services include: ordered by a Physician,and rendered under the supervision of a Registered Nurse; 1. room and board In a semi-private room when confined as an inpatient,unless the 3. medical social services; patient must be isolated from others for 4. nutritional guidance; documented clinical reasons; 5. respiratory,or inhalation therapy(e.g., 2. intensive care units,including cardiac, oxygen);and progressive and neonatal care; 6. Physical Therapy by a Physical Therapist, 3. use of operating and recovery rooms; Occupational Therapy by a Occupational 4. use of emergency rooms; Therapist,and Speech Therapy by a Speech Therapist. 5. respiratory,pulmonary,or inhalation therapy Exeluslons: (e.g.,oxygen); 8. drugs and medicines administered(except 1. homemaker or domestic maid services; for lake home drugs)by the Hospital; 2. sitter or companion services; 7, intravenous solutions; 3. Services rendered by an employee or 8. administration of,Including the cost of, operator of an adult congregate living whole blood or blood products except as facility;an adult foster home;an adult day outlined in the Drugs exclusion of the'What care center,or a nursing home facility; Is Not Covered?section); 14. Speech Therapy provided fora diagnosis of 9. dressings, Including ordinary casts; developmental delay; 15. Custodial Care except for any such care 10. anesthetics and their administration; covered under this subsection when 11. transfusion supplies and equipment; provided on a part-time or intermittent basis 12. diagnostic Services,Including radiology, (as defined above)by a home health aide; ultrasound,laboratory,pathology and 16. food,housing,and home delivered meals; approved machine testing(e.g., EKG); and 13. Physical,Speech,Occupational,and 17. Services rendered in a Hospital,nursing Cardiac Therapies;and home,or Intermediate care facility. 14. transplants as described In the Transplant Services subsection. Hospice Services Exclusion: Health Care Services provided in connection with a Hospice treatment program may be Expenses for the following Hospital Services are Covered Services,provided the Hospice excluded when such Services could have been treatment program is: • provided without admitting you to the Hospital: 1)room and board provided during the 1. approved by your Physician;and admission;2)Physician visits provided while you 2. your doctor has certified to us In writing that were an Inpatient;3)Occupational Therapy, your life expectancy is 12 months or less. Speech Therapy, Physical Therapy,and Cardiac Therapy;end 4)other Services provided while Recertification is required every six months. you were an inpatient. Malls Covered? 29 In addition,expenses for the following and Exclusion; similar items are also excluded: All Substance Dependency,drug and alcohol 1. gowns and slippers; related diagnoses,(except as covered in the 2. shampoo,toothpaste,body lotions and 'Mental Health Services"and'Substance hygiene packets; Dependency Care and Treatment Services" catemodes).Pain Management,and respiratory 3. lake-home drugs; ventilator management Services are excluded. 4. telephone and television; Mammograms 5. guest meals or gourmet menus;and Mammograms obtained in a medical office, 6. admission kits. medical treatment facility or through a health testing service that uses radiological equipment Inpatient Rehabilitation registered with the appropriate Florida regulatory agencies(or those of another state)for Inpatient Rehabilitation Services are covered diagnostic purposes or breast cancer screening • when the following criteria are met: are Covered Services. 1. Services must be provided under the Benefits for mammograms may not be subject to direction of a Physician and must be the Deductible,Coinsurance,or Copayment(if provided by a Medicare certified facility in applicable). Please refer to your Schedule of accordance with a comprehensive Benefits for more information. rehabilitation program; Mastectomy Services 2. a plan of care must be developed and - -- managed by a coordinated multi-disciplinary Breast cancer treatment including treatment for team; physical complications relating to a Mastectomy (Including lymphedemas),and outpatient post- 3. coverage is subject to our Medical Necessity surgical follow-up in accordance with prevailing coverage criteria then in effect; medical standards as determined by you and 14. the individual must be able to actively your attending Physician are covered. participate in at least 2 rehabilitative Outpatient post-surgical follow-up care for therapies and be able to tolerate at least 3 Mastectomy Services shall be covered when hours per day of skilled Rehabilitation provided by a Provider in accordance with the Services for at least 5 days a week and their prevailing medical standards and at the most Condition must be likely to result in medically appropriate setting. The setting may significant improvement;and be the Hospital, Physician's office, outpatient center,or your home. The treating Physician, 15. the Rehabilitation Services must be required after consultation with you,may choose the at such intensity,frequency and duration appropriate setting. that further progress cannot be achieved in a less intensive setting. Maternity Services I Inpatient Rehabilitation Services are subject to Health Care Services, including prenatal care, the inpatient facility Copayment,if applicable, delivery and postpartum care and assessment, and the benefit maximum set forth in the provided to you,by a Doctor of Medicine(M.D.), Schedule of Benefits. Doctor of Osteopathy(D.0.), Hospital,Birth Center,Midwife or Certified Nurse Midwife may What Is Covered? 2.10 a be Covered Services. Care for the mother Medical Pharmacy includes the postpartum assessment. Physician-administered Prescription Drugs In order for the postpartum assessment to be which are rendered in a Physician's office are covered,such assessment must be provided at subject to a separate Cost Share amount that is a Hospital,an attending Physician's office,an in addition to the office visit Cost Share amount. outpatient maternity center,or in the home by a The Medical Pharmacy Cost Share amount qualified licensed health care professional applies to the Prescription Drug and does not trained in care for a mother. Coverage under include the administration of the Prescription (his Booklet(or the postpartum assessment Drug. includes coverage for the physical assessment Your plan may also Include a maximum monthly of the mother and any necessary clinical tests in amount you will be required to pay out-of-pocket keeping with prevailing medical standards, for Medical Pharmacy,when such Services are I Under Federal law,your Group Plan generally provided by an In-Network Provider or Specialty may not restrict benefits for any hospital length Pharmacy. If your plan includes a Medical of stay in connection with childbirth for the Pharmacy out-of-pocket monthly maximum,it will be listed on your Schedule of Benefits and mother or newborn child to less than 48 hours only applies after you have met your Deductible, following a vaginal delivery;or less than 96 If applicable. hours following a cesarean section. However, Federal law generally does not prohibit the Please refer to your Schedule of Benefits for the mother's or newborn's attending Provider, after additional Cost Share amount endfor monthly consulting with the mother,from discharging the maximum out-of-pocket applicable to Medical mother or her newborn earlier than 48 hours(or Pharmacy for your plan. 96 as-applicable). In any case,under Federal Note: For purposes of this benefit,allergy law,your Group Plan can only require that a Injections and Immunizations are not considered provider obtain authorization for prescribing an Medical Pharmacy. inpatient hospital stay that exceeds 48 hours(or MaaN{ileakk-SeaWaec 96 hours). Fxnlusiom Maternity Services rendered to a Covered k'y"" "Y" ^"Y p'r k..kej"""r`"",^I Person who becomes pregnant as a Gestational Surrogate under the terns of,and in accordance ^^""`^^^ ^ ^'^^•"^•^^y k^^^v^.�.q• with, a Gestational Surrogacy Contract or r^ •,•^" <^,•-'^^^ m"y krdedei Arrangement are excluded. This exclusion a , ; ; ,,; ,,,^;,ni applies to all expenses for prenatal, Infra-portal, and post-partal Maternity/Obstetrical Care,and 2. "I"ec''a 9"tp°tiool aireett-(raadawe+e Health Care Services rendered to the Covered Person acting as a Gestational Surrogate. 3.—papiaN,lespita;iaagera•:-ea,dafwed-in-Uws For the definition of Gestational Surrogate and fir' r"^.'"e"—.4^•a^^"fir—non Gestational Surrogacy Contract,see the file-physician, •Definitions•section of this Benefit Booklet. &sateelek: ' -ter“iii-s-rerd—orl'r a Ce"di"ao t"a' a I"-oat,cod"^...,.. rv..^-"^-P' 'nfi-O it What is Covered] 241 Na lag Hospital,the attending Physician's office,a Birth eai•^•1^'^"'' ^'th^a''--Vert Center,or in the home by a Physician,Midwife ^_S� ^. A L J, ✓ or Certified Nurse Midwife,and the performance of any necessary clinical tests and ^ ^^ ning w,^^L ^--, ^^ ^-••� immunizations are within prevailing medical standards. These Services are not subject to elisabIldw the Deductible. 't e.--•'-^s b-y^ed He po•'ed,e-e-e-ry lec Ambulance Services,when necessary to eeelae transport the newborn child to and from the newest appropriate facility which Is staffed and S gone. -I'. ' equipped to treat the newborn child's Condition, nested 1^a•'a^I^'a^" "-^•^••^^'^^•"^•^^ as determined by BCBSF or Monroe County BOCC and certified by the attending Physician aadedyi as Medically Necessary to protect the health and safety of the newborn child,are covered. ai-ESeA44084OF-041S4-13411144.9•118•43Fieetiossi-eoUnder Federal law,your Group Plan generally a•�•+ --^^^^a"'^^^•P--^'^�r may not restrict benefits for any hospital length prebegark of slay in connection with childbirth for the 7. ceN'^^s fo't^st'ng e'aptitude,ability, mother or newborn child to less Man 48 hours following a vaginal delivery;or less than 96 hours following a cesarean section. However, _ Federal law generally does not prohibit the mother's or newborn's attending Provider,after consulting with the mother,from discharging the mother or her newborn earlier than 48 hours(or 96 as applicable). In any case,under Federal law,your Group Plan can only require that a baa.J...lo..o .,.,.gwf.....:._.........Ir.F provider obtain authorization for prescribing an inpatient hospital stay that exceeds 48 hours(or al:-inpatient-(ever-night)+nentaihealth-Sewiaes 96 hours). Newborn Care Orthotic Devices A newborn child will be covered from the Orthotic Devices Including braces and trusses moment of birth provided that the newborn child for the leg,arm,neck and back,and special is eligible for coverage and properly enrolled.- surgical corsets are covered when prescribed by Covered Services shall consist of coverage for a Physician and designed and fitted by an injury or sickness,Including the necessary care Orfhotisl. or treatment of medically diagnosed congenital Benefits may be provided for necessary defects,birth abnormalities,and premature birth. replacement of an Orthotic Device which Is Newborn Assessmen(: owned by you when due to irreparable damage, wear,a change in your Condition,or when An assessment of the newborn child is covered necessitated due to growth of a child. provided the Services were rendered at a What Is Coveted? 242 Payment for splints for the treatment of Exclusion: temporomandibular joint("TMJ')dysfunction is 1. Expenses for arch supports, shoe Inserts limited to payment for one splint in a six-month designed to effect conformational changes period unless a more frequent replacement is in the foot or foot alignment,orthopedic determined by BCBSF or Monroe County BOCC shoes,over-the-counter,custom-made or to be Medically Necessary. 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 Inserts 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 cranicsynostosis;and 3. Expenses for devices necessary to exercise, train,or participate in sports,e.g.custom- made knee braces. Osteoporosis Screening, Diagnosis,and Treatment Screening,diagnosis,and treatment of osteoporosis for high-risk individuals is covered as medically necessary, 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 glucocorticold(steroid)therapy;or 4. individuals who have primary hyperparauiyroidism, and 5, individualslndividuals who have a family history of osteoporosis. Whal Is Coveted? 2-13 I Outpatient Cardiac,Occupational,Physical, Payment Guidelines for Massage and Speech,Massage Therapies and Spinal Physical Therapy I Manipulation Services 1. Payment for covered Massage Services is Outpatient therapies listed below may be limited to no more than four(4) 15-minute Covered Services when ordered by a Physician Massage treatments per day,not to exceed or other health care professional licensed to the Outpatient Cardiac,Occupational, perform such Services. The outpatient therapies Physical,Speech,and Massage Therapies listed in this category are In addition to the and Spinal Manipulations benefit maximum Cardiac,Occupational, Physical and Speech listed on the Schedule of Benefits. I Therapy benefits listed in the Home Health 2. Payment for a combination of covered Care,Hospital,and Skilled Nursing Facility Massage and Physical Therapy Services categories herein. rendered on the same day is limited to no Cardiac Therapy Services provided under the more than four(4)15-minute treatments per supervision of a Physician,or an appropriate day for combined Massage and Physical Provider trained for Cardiac Therapy,for the Therapy V atment,Cardiac not to exceed the purpose of aiding in the restoration of normal Outpatient Cardiac,Occupational.Physical, heart function in connection with a myocardial Speech,and Massage Therapies and Spinal Manipulations benefit maximumaximumth listed on the infarction,coronary occlusion or coronary Schedule of Benefits. bypass surgery are covered. 3. Payment for covered Physical Therapy Occupational Therapy Services provided by a Services rendered on the same day as Physician or Occupational Therapist for the spinal manipulation is limited to one(1) purpose of aiding in the restoration of a Physical Therapy treatment per day not to - previously impaired(unction lost due to a exceed fifteen(15)minutes in length. Condition are covered. Spinal Manipulations: Services by Physicians Speech Therapy Services of a Physician, for manipulations of the spine to correct a slight Speech Therapist,or licensed audiologist to aid dislocation of a bone or joint that is in the restoration of speech loss or an demonstrated by x-ray are covered. impairment of speech resulting from a Condition Payment Guidelines for Spinal Manipulation are covered. Physical Therapy Services provided by a 1. Payment for covered spinal manipulation Is Physician or Physical Therapist for the purpose limited to no more than 26 spinal of aiding in the restoration of normal physical manipulations per Benefit Period,or the function lost due to a Condition are covered. maximum benefit listed in the Schedule of Benefits,whichever occurs first. Massage Therapy Massage provided by a 2, Payment for covered Physical Therapy Physician,Massage Therapist.or Physical Therapist when the Massage Is prescribed as Services rendered on the same day as a being Medically Necessary by a Physician spinal manipulation is limited to one(1) licensed pursuant to Florida Statutes Chapter Physical Therapy treatment per day,not to 458(Medical Practice),Chapter 459 exceed fifteen(15)minutes in length. I (Osteopathy).Chapter 460(Chiropractic)or Your Schedule of Benefits sets forth the Chapter 461 (Podiatry)is covered. The maximum number of visits covered under this Physician's prescription must specify the plan for any combination of the outpatient number of treatments. therapies and spinal manipulation Services listed above. For example,even if you may What is Co end? 2,14 have only been administered Iwo(2)of the Services,or another physician of the same spinal manipulations for the Benefit Period,any specialty who belongs to the same group additional spinal manipulations for that Benefit practice as that Physician,within the past three Period will not be covered if you have already years. met the combined therapy visit maximum with other Services. Fxclusiorr Oxygen Expenses for online medical Services provided electronically through a computer by a Physician Expenses for oxygen,the equipment necessary via the Internet other than through a healthcare to administer it,and the administration of oxygen communication services vendor that has entered are covered. into contract with BCBSF are excluded. Physician Services Expenses for online medical Services provided by a health care provider that Is not a Physician I Medical or surgical Health Care Services and expenses for Health Care Services provided by a Physician, including Services rendered by telephone are also excluded. rendered in the Physician's office,in an outpatient facility,or electronically through a Preventive Health Services computer via the Internet. Preventive Services are covered for both adults and children based on prevailing medical I Payment Guidelines for Physician Services standards and recommendations which are Provided by Electronic Means through a explained further below. Some examples of Computer: preventive health Services Include, but am not Expenses for online medical Services provided limited to,periodic routine health exams,routine etectrodcally through a computer by a Physician gynecological exams,immunizations and related via the Internet will be covered only if such preventive Services such as Prostate Specific Services: Antigen(PSA),routine mammograms and pap 1. were provided to a covered individual who smears. In order to be covered,Services shall be provided in accordance with prevailing was,at the time the Services were provided, medical standards consistent with: an established patient of the Physician rendering the Services; 1. evidence-based Items or Services that have in effect a rating of'A'or'13'in the current 12. were in response to an online inquiry recommendations of the U.S.Preventive received through the Internet from the Services Task Force established under the covered Individual with respect to which the public Health Service Act; Services were provided;and 2. Immunizations that have in effect a 3. were provided by a Physician through a recsecure online healthcare communication Committee on Immunization frum tag Advr cry --services vendor that,at the time the Committee on ontrol Practices of the Centers for Disease Control and Prevention Services were rendered,was under contract established under the Public Health Service with BCBSF. Act with respect to the individual involved; The term"established patient,'as used herein, 3. with respect to infants,children,and shall mean that the covered individual has adolescents,evidence-Informed preventive received professional services from the care and screenings provided for in the Physician who provided the online medical WMI Is Gwent? 2.15 comprehensive guidelines supported by the Note: From time to time medical standards that Health Resources and Services ere based on the recommendations of the Administration;and entities listed in numbers 1 throuoh 4 above 4, with respect to women,such additional change. Services may be added to the preventive care and screenings not recommendations and sometimes may be described in paragraph number one as removed. It Is Important to understand that your provided for in comprehensive guidelines coverage for these preventive Services is based supported by the Health Resources and on what is In effect on your Effective Date. If Services Administration. Women's any of the recommendations or auidelines preventive coverage under this category change after your Effective Date,your coverage Includes: will not change until your Group's first Anniversary Dale one year after the a. well-woman visits; recommendations or Guidelines 0o into effect. b. screening for gestational diabetes; For example,if the USPSTF adds a new c. human papillomavirus testing; recommendation for a preventive Service that we do not cover and you are already covered d. counseling for sexually transmitted under this Benefit Booklet;that new Service will infections; not be a Covered Service under this category e. counseling end screening for human right away, The coverage for a new Service will immune-deficiency virus; start on your Group's Anniversary Date one year f. contraceptive methods and counseling; OW the new recommendation goes Into effect. screening and counseling for Exclusion: interpersonal and domestic violence; Routine vision and hearing examinations and and screenings are not covered as Preventive Heattp h. breastfeeding support, supplies and Services,except as required under paragraph counseling.-Breaa#eedMgsuppliesare number one andfor number three above.•-Sterilization procedures covered under pregaansy Breastfeedino supplies are this category are limited to tuballigatiensahose limited to breast Rumps, You must procedures indicated as covered in the obtain prior coverage authorization Medication Guide only.-Contraceptive implants from us before you get the breast are limited to Infra-uterine devices(IUD) pump. Breast pumps must be obtained indicated as covered in the Medication Guide through a Durable Medical Equipment only,Including insertion and removal. Provider who must be able to verify that Limitations you are either scheduled for delivery or --have delivered within 9 months. In- Breast oumps are limited to: Network benefits are only available a. one manual or electric breast Dump per through our preferred Durable Medical pregnancy, in connection with childbirth: Equipment Provider, If you do not obtain prior coverage authorization we b, the most cost-effective Duma as determine4 will not make any payment for such by Vs(please see the Durable Medical Service. fnuioment category in this section for additional information). Whet Is Covered/ 2.16 c. hospital-wade breast pumas are not 1. Self-Administered Prescription Drugs used covered except when Medically Necessary In the treatment of diabetes,cancer, during an inpatient slay.In accordance with Conditions requiring immediate stabilization our Medical Necessity coverage criteria in (e.g.anaphylaxis),or in the administration of effect at the time Services are provided. dialysis;and Prosthetic Devices 2. Self-Administered Prescription Drugs The following Prosthetic Devices are covered identified as Specialty Drugs with a special when prescribed by a Physician and designed symbol in the Medication Guide when and fitted by a Proslhellsl: delivered to you at home and purchased at a Specialty Pharmacy or an Out-of-Network 1. artificial hands,arms, feet,legs and eyes, Provider that provides Specialty Drugs. including permanent implanted lenses following cataract surgery,cardiac 3. Specialty Drugs used to Increase height or pacemakers,and prosthetic devices incident bone growth(e.g.,growth hormone),must to a Mastectomy; meet the following criteria in order to be covered: I 2. appliances needed to effectively use artificial limbs or corrective braces;or a. Must be prescribed for Conditions of growth hormone deficiency documented 3. penile prosthesis. with two abnormally low stimulation Covered Prosthetic Devices(except cardiac tests of less than 10 ng/ml and one pacemakers,and Prosthetic Devices incident to abnormally low growth hormone Mastectomy)ere limited to the first such dependent peptide or for Conditions of permanent prosthesis(including the first growth hormone deficiency associated temporary prosthesis if it is determined to be with loss of pituitary function due to necessary)prescribed for each specific trauma,surgery,tumors,radiation or Condition. disease,or fa state mandated use as in patients with AIDS. IBenefits may be provided for necessary replacement of a Prosthetic Device which Is b. Continuation of growth hormone therapy owned by you when due to irreparable damage, is only covered for Conditions wear,or a change in your Condition,or when associated with significant growth necessitated due to growth of a child. hormone deficiency when there is evidence of continued responsiveness Exclusion: to treatment. Treatment is considered 1. Expenses for microprocessor controlled or responsive in children less than 21 myoelectric artificial limbs(e.g.C-legs):and years of age,when the growth hormone dependent peptide(IGF-1)is in the 12. Expenses for cosmetic enhancements to normal range for age end Tanner artificial limbs. development stage;the growth velocity is at least 2 cm per year,and studies Self-Administered Prescription Drugs demonstrate open epiphyses. The following Self-Administered Drugs ere Treatment 15 considered responsive In covered: both adolescents with closed epiphyses and for adults,who continue to evidence growth hormone deficiency and the IGF- Whit I.wcn.a? 1-11/ 1 remains in the normal range for age and gender. evipakent-erany-sembk+ation hereof Skilled Nursing Facilities provided-M'aRnysiaianr-Rsyskelegist-er Mental Heal h-PrefessienaWna-pregram The following Health Care Services may be Covered Services when you are an inpatient in a I+^pa^^or Skilled Nursing Facility: approved-by the 1. room and board: �rSabstance Dapendamey, 2. respiratory, pulmonary,or inhalation therapy (e.g.,oxygen); Wealik Prefeselen 4ealpaient vote fer the 3. drugs and medicines administered while an inpatient(except lake home drugs); Grpendeney 4. Intravenous solutions: Exsirrster* 6. administration of,Including the cost of, Expenses-fer-prolonged care-andareelment-ef whole blood or blood products(except as Substance-©epeadeney-in-a-speslakted outlined in the Drugs exclusion of the"What inpatient-ePresklential-fasilky-ePiripatient Is Not Covered?*section); senanementc teat,re primarily'nt^^"^"^r 6. dressings,Including ordinary casts; shaageeFenvkenmentare-eseluded• 7. transfusion supplies end equipment; Surgical Assistant Services 6. diagnostic Services,including radiology, Services rendered by a Physician,Registered ultrasound,laboratory,pathology and Nurse First Assistant or Physician Assistant approved machine testing(e.g.. EKG); when acting as a surgical assistant(provided no 9. chemotherapy treatment for proven intern,resident,or other staff physician is malignant disease;and available)when the assistant is necessary are 10. Physical, Speech,and Occupational covered. Therapies.; Surgical Procedures A treatment plan from your Physician may be Surgical procedures performed by a Physician required In order to determine coverage and may be covered including the following: payment. 1. sterilization Rubel ligation and Exclusion: vasectomies),regardless of Medical Expenses for an inpatient admission to a Skilled Necessity; Nursing Facility for purposes of Custodial Care, 2. surgery to correct deformity which was convalescent care,or any other Service caused by disease,trauma,birth defects, primarily for the convenience of you and/or your growth defects or prior therapeutic family members or the Provider are excluded. processes; Sub Wa 3. oral surgical procedures for excisions of tumors,cysts,abscesses, and lesions of the r--^n"'-w'-s^4 re.ea"c,^r-e Depe^s^ray mouth; Ong' 4. surgical procedures Involving bones or joints of the jaw(e.g.,temporomandibular joint Meth Covered? 2-1a (TMJJ)and facial region If,under accepted will be based on 50 percent of the Allowed medical standards,such surgery Is Amount for any secondary surgical necessary to treat Conditions caused by procedure(s)performed. In addition, congenital or developmental deformity. Coinsurance or Copayment(if any)indicated disease,or Injury; in your Schedule of Benefits will apply. This 5. Services of a Physician for the purpose of guideline is applicable to all bilateral rendering a second surgical opinion and procedures and all surgical procedures related diagnostic services to help determine performed on the same dale of service. the need for surgery;and 2. Payment for incidental surgical procedures 8: surgical procedures performed on a Covered Is limited to the Allowed Amount for the Plan Participant for the treatment of Morbid primary procedure,and there is no Obesity(e.g.,intestinal bypass,stomach additional payment for any Incidental stapling,balloon dilation)and the associated procedure. An'Incidental surgical care provided the Covered Plan Participant procedure'includes surgery where one,or has not previously undergone the same or more than one,surgical procedure is similar procedure in the lifetime of this performed through the same incision or Group Health Plan when medically operative approach as the primary surgical necessary. procedure which, in BCBSF's or Monroe Exclusion; County BOCC's opinion,is not clearly identified and/or does not add significant a. Surgical procedures for the treatment of time or complexity to the surgical session. Morbid Obesity including:intestinal For example,the removal of a normal bypass;stomach stapling;balloon appendix performed in conjunction with a dilation and associated care for the Medically Necessary hysterectomy is an surgical treatment of Morbid Obesity,if incidental surgical procedure(I.e.,there Is the Covered Plan Participant has no payment for the removal of the normal previously undergone the same or appendix In the example). similar procedures in the lifetime of this 3. Payment for surgical procedures for fracture Group Health Plan. Surgical procedures care,dislocation treatment,debridement, performed to revise,or correct defects wound repair,unna boot,and other related related to,a prior intestinal bypass, Health Care Services,is Included In the stomach stapling or balloon dilation are Allowed Amount of the surgical procedure. also excluded. b. Reversal of a weight loss surgery, Transplant Services surgical procedures to revise,correct, Transplant Services,limited to the procedures and correction of defects to include listed below,may be covered when performed at adjustment to devices implanted or any a facility acceptable to 8CBSF or Monroe Ms not performed during the initial County BOCC,subject to the conditions and surgical event, limitations described below. Payment Guidelines for Surgical Procedures Transplant includes pre-transplant,transplant 1. Payment for multiple surgical procedures and post-discharge Services,and treatment of performed in addition to the primary surgical complications after transplantation. Benefits will procedure,on the same or different areas of only be paid for Services,care and treatment the body,during the same operative session received or provided in connection with a: WIW is Coat? 2-19 1. Bone Marrow Transplant,as defined herein, which Is specifically listed in the rule 59B- 12.001 of the Florida Administrative Code or any successor or similar rule or covered by Medicare as described in the most recently published Medicare Coverage Issues Manual issued by the Centers 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 you and will be subject to the same limitations and exclusions as would be applicable to you. Coverage for the reasonable expenses of searching for the donor will be limited to a search 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; B. pancreas transplant performed simultaneously with a kidney transplant;or 9. lung-whole single or whale bilateral transplant. Coverage will be provided for 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 carder,organization or person other than the donors family or estate. I You may call the customer service phone number indicated in this Booklet or on your Identification Card in order to determine which Bone Marrow Transplants are covered under this Booklet. What Is Covered? 2-20 exclusions: Expenses for the following are excluded: 1. transplant procedures not included in the 1st above,or otherwise excluded under this Booklet(e.g.,Experimental or Investigational transplant procedures): 2. transplant procedures involving the transplantation or implantation of any non- human organ or tissue; 3. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered under this Benefit Booklet; 4. transplant procedures involving the implant of an artificial organ,including the implant of the artificial organ: 5. any organ,tissue,marrow,or stem cells which Ware sold rather than donated; 6. any Bone Marrow Transplant,as defined herein,which is not specifically listed in rule 598-42.001 of the Florida Administrative Code or any successor or similar rule or covered by Medicare pursuant to a national coverage decision made by the Centers for Medicare and Medicaid Services as evidenced in the most recently published Medicare Coverage Issues Manual; 7. any Service in connection with the identification of a donor from a local,state or national listing,except in the case of a Bone Marrow Transplant; 8. any non-medical costs,Including but not limited to,temporary lodging or transportation costs for you and/or your famly to and from lheapproved facility;and 9. any artificial heart or mechanical device that replaces either the atrium andfor the ventricle. Whet Is Covered? 241 Section 3: What Is Not Covered? Introduction clinical ecology;chelation therapy; thermography;mind-body interactions such as Your Booklet expressly excludes expenses for meditation,imagery,yoga,dance,and art the following Health Care Services,supplies, therapy;biofeedback;prayer and mental drugs or charges. The following exclusions are healing:manual healing methods such as the In addition to any exclusions specified in the Alexander technique,aromatherapy,Ayurvedic 'What Is Covered?"section or any other section message,cranbsacral balancing,Feldenkrais of the Booklet. method, Hellerwork,polarity therapy, Reichian Abortions which are elective. therapy,reflexology,roifing,shiatsu,traditional Chinese massage,Trager therapy,trigger-point Arch Supports,shoe inserts designed to effect myotherapy, and biofield therapeutics; Reiki, conformational changes in the foot or foot SHEN therapy,and therapeutic touch; alignment,orthopedic shoes,over-the-counter, bioelectromagnetic applications in medicine;and custom-made or built-up shoes,cast shoes, herbal therapies. sneakers,ready-made compression hose or Complications of Non-Covered Services, support hose,or similar type devices/appliances regardless of intended use,except for Including the diagnosis or treatment of any therapeutic shoes(including inserts andlor Condition which is a complication of a non- therapeutic shoes the treatment of severe covered Health Care Service(e.g., Health Care diabetic foot disease. Services to treat a complication of cosmetic surgery are not covered), Assisted Reproductive Therapy(Infertility) including, but not limited to,associated Services, Contraceptive medications,devices, supplies,and medications for In Vitro appliances,or other Health Care Services when FertilimUon(IVF);Gamete Inlrelaflopien provided for contraception,except when Transfer(GIFT)procedures;Zygote indicated as covered,under the Preventive Intrafallopian Transfer(ZIFT)procedures; Health Services category of the"What Is Artificial Insemination(Al);embryo transport; Covered?"section. surrogate parenting;donor semen and related Cosmetic Services, Including any Service to costs Including collection and preparation;and improve the appearance or self-perception of an infertility treatment medication. individual(except as covered under the Breast Autopsy or postmortem examination services, Reconstructive Surgery category).including and unless specifically requested by BCBSF or without limitation: cosmetic surgery and Monroe County BOCC. procedures or supplies to correct hair loss or skin wrinkling(e.g.,Minoxidil,Rogaine,Retin-A), Complementary or Alternative Medicine and hair Implants/transplants. including, but not limited to,self-care or self-help training;homeopathic medicine and counseling; Costs related to telephone consultations,failure Ayurvedic medicine such as lifestyle to keep a scheduled appointment,or completion modifications and purification therapies; of any form and/or medical Information. traditional Oriental medicine including Custodial Care and any service of a custodial acupuncture;naturopathic medicine; nature, including and without limitation: Health environmental medicine including the field of Care Services primarily to assist in the activities What le**Coveted? ].t of daily living;rest homes;home companions or treatment of cancer that have not been sitters;home parents;domestic maid services; approved for any indication are excluded. respite care;and provision of services which are for the sole purposes of allowing a family 2. All drugs dispensed to,or purchased by,you member or caregiver of a Covered Person to from a pharmacy. This exclusion does not return to work. apply to drugs dispensed to you when: a. you are an Inpatient in a Hospital, Dental Care or treatment of the teeth or their Ambulatory Surgical Center.Skilled supporting structures or gums,or dental Nursing Facility,Psychiatric Facility or a procedures,including but not limited to: Hospice facility; extraction of teeth, restoration of teeth with or without fillings,crowns or other materials, b. you are in the outpatient department of bridges,cleaning of teeth,dental implants, a Hospital: dentures,periodontal or endodontic procedures, c. dispensed to your Physician for orthodontic treatment(e.g., braces).inlreoral administration to you In the Physician's prosthetic devices, palatal expansion devices, office and prior coverage authorization Ibruxism appliances,and dental x-rays. This has been obtained(if required);aad exclusion also applies to Phase II treatments(as defined by the American Dental Association)for d. you are receiving Home Health Care TMJ dysfunction. This exclusion does not apply according to a plan of treatment and the to an Accidental Dental Injury and the Child Cleft Home Health Care Agency bills us for Lip and Cleft Palate Treatment Services such drugs,Including Self-Adminislarod category as described in the What Is Covered?' Prescription Drugs that are rendered In section. connection with a nursing visit.; 3:,�,Any non-Prescription medicines,remedies, Drugs vaccines,biological products(except 1. Prescribed for uses other than the Food and insulin),pharmaceuticals or chemical Drug Administration(FDA)approved label compounds,vitamins,mineral supplements, indications. This exclusion does not apply to fluoride products, over-the-counter drugs, any drug that has been proven safe, products,or health foods,except as effective and accepted for the treatment of described in the Preventive Health Services the specific medical Condition for which the category of the-What Is Covered?-section. drug has been prescribed,as evidenced by the results of good quality controlled clinical Any drug which is indicated or used for studies published in at least two or moresexual dysfunction(e.g.,Clans.Levitra, peer-reviewed hill length articles in Viagra,Cavilled). The exception described respected national professional medical in exclusion number one above does not journals. This exclusion also does not apply apply to sexual dysfunction drugs excluded to any drug prescribed for the treatment of under this paragraph. cancer that has been approved by the FDA 5.--_Any Sell-Administered Prescription Drug for at least one Indication,provided the drug net Indicated as covered in the"What Is Is recognized for treatment of your particular Covered?"section of this Benefit Booklet. cancer in a Standard Reference 6. Blood or blood Compendium or recommended for treatment products used to treat hemophilia,except when provided of your particular cancer in Medical to you Literature. Drugsfor: g prescribed For the Whin Is nor Covered? 3-3 a. emergency stabilization; arches:chronic foot strain;trimming of toenails b. during a covered inpatient stay;or corns,or calluses. c. when proximately related to a surgical General Exclusions include,but are notlimited procedure. to: The exceptions to the exclusion for drugs 1. any Health Care Service received prior to purchased or dispensed by a pharmacy your Effective Dale or after the date your described in subparagraph number two do coverage terminates; not apply to hemophilia drugs excluded 2. any Service to diagnose or treat any under this subparagraph. Condition resulting from or in connection 7. Drugs,which require prior coverage with your jab or employment; authorization when prior coverage 3. any Health Care Services not within the authorization Is not obtained. service categories described in the"What is 8. Specialty Drugs used to increase height or Covered?section,any rider,or bone growth(e.g.,growth hormone)except Endorsement attached hereto, unless such for Conditions of growth hormone deficiency services are specifically required to be documented with two abnormally low covered by applicable law, stimulation tests of less than 10 ngfml and 4. any Health Care Services provided by a one abnormally low growth hormone Physician or other health care Provider dependent peptide or for Conditions of related to you by blood or marriage; growth hormone deficiency associated with loss of pituitary function due to trauma, 5. any Health Care Service which is not surgery,tumors, radiation or disease,or for Medically Necessary as determined by us or state mandated use as in patients with Monroe County BOCC and defined In this AIDS. Booklet. The ordering of a Service by a health care Provider does not in itself make Continuation of growth hormone therapy will such Service Medically Necessary or a not be covered except for Conditions Covered Service; associated with significant growth hormone deficiency when there is evidence of 6. any Health Care Services rendered at no continued responsiveness to treatment. charge; (See"What is Covered?"section for 7. expenses for claims denied because we did additional Information.) not receive Information requested from you Experimental or Investigational Services, regarding whether or not you have other except as otherwise covered under the Bone coverage and the details of such coverage; Marrow Transplant provision of the Transplant 8. any Health Care Services to diagnose or Services category. treat a Condition which,directly or indirectly, Food and Food Products prescribed or not, resulted from or Is In connection with: except as covered in the Enteral Formulas a) war or an act of war,whether declared subsection of the"What Is Covered?section. or not; Foot Care which is routine, including any Health b) your participation in,or commission of. Care Service, in the absence of disease. This any act punishable by law as a exclusion Includes, but is not limited to: non• misdemeanor or felony,or which surgical treatment of bunions;flat feet;fallen constitutes riot,or rebellion; Mal is Not covered? 3.3 c) your engaging in an illegal occupation; with,a Gestational Surrogacy Contract or d) Services received at military or Arrangement. This exclusion applies to all government facilities:Of expenses for prenatal,intra-partal, and post- e) Services received to treat a Condition penal MatemIty/Obstetrical Care, and Health arising out of your service In the armed Care Services rendered to the Covered Person forces,reserves and/or National Guard; acting as a Gestational Surrogate. Qr For the definition of Gestational Surrogate and Gestational Surrogacy Contract see the f) Services that are not patient-specific,as Definitions section of this Benefit Booklet. determined solely by us. Oral Surgery except as provided under the 9. Health Care Services rendered because 'What Is Covered?"section. they were ordered by a court,unless such Services are Covered Services under this Orthomolecular Therapy Including nutrients, Benefit Booklet;-and vitamins,and food supplements. 10. any Health Care Services rendered by or Oversight of a medical laboratory by a through a medical or dental department Physician or other health care Provider. maintained by or on behalf of an employer, "Oversight"as used in this exclusion shall, mutual association,labor union,trust,or include, but is not limited to,the oversight of: similar person or group;or 1. the laboratory to assure timeliness, 11. Health Care Services that are not direct, reliability,and/or usefulness of test results: hands-on,and patient specific,including,but 2. the calibration of laboratory machines or not limited to the oversight of a medical testing of laboratory equipment; Laboratory to assure timeriness,reliability. and/or usefulness of test results,or the 3. the preparation,review or updating of any oversight of the calibration of laboratory protocol or procedure created or reviewed machines,equipment,or laboratory by a Physician or other health care Provider technicians. in connection with the operation of the laboratory;and Genetic screening, Including the evaluation of genes to determine If you are a carrier of an 4. laboratory equipment or laboratory abnormalgene thatputs personnel for any reason. you at risk for a Condition,except as provided under the Personal Comfort,Hygiene or Convenience Preventive Health Services category of the Items and Services deemed to be not Medically 'What Is Covered?'section. Necessary and not directly related to your Hearing Aids(external or implantable)and treatment Including,but not limited to: Services related to the fitting or provision of 1, beauty and barber services; hearing aids,including tinnitus maskers, 2. clothing including support hose; batteries,and cost of repair. 3. radio and television; Immunizations except those covered under the 4. guest meals and accommodations; Preventive Health Services category of the 5. telephone charges: 'What Is Covered?'section. 6. take-home supplies; Maternity Services rendered to a Covered 7. travel expenses(other then Medically Person who becomes pregnant as a Gestational Necessary Ambulance Services); Surrogate under the terms of,and in accordance What Is Na Cowed? Yx 8. motel/hotel accommodations; activities;a expenses related to physical 9. air conditioners,furnaces,air filters,air or conditioning programs such as athletic training, water purification systems,water softening bodybuilding,exercise,fitness,flexibility,and systems,humidifiers,dehumidifiers,vacuum diversion or general motivation. cleaners or any other similar equipment and Training and Educational Programs,or devices used for environmental control or to materials,including,but not limited to programs enhance an environmental setting; or materials for pain management and 10. hot tubs,Jacuzzis,heated spas,pools,or vocational rehabilitation,except as provided memberships to health clubs; under the Diabetes Outpatient Self Management 11. heating pads, hot water bottles,or Ice packs; category of the'What Is Covered?"section. 12, physical fitness equipment; Travel or vacation expenses even if prescribed 13. hand rails and grab bars;and or ordered by a Provider. 14. Massages except as covered in the"What is Volunteer Services or Services which would Covered?"section of this Booklet. normally be provided free of charge and any Private Duty Nursing Care rendered at any charges associated with Deductible, location. Coinsurance,or Copayment(if applicable) Rehabilitative Therapies provided on an requirements which are waived by a health care inpatient or outpatient basis,except as provided Provider. in the Hospital, Skilled Nursing Facility,Home Weight Control Services Including any service Health Care,and Outpatient Cardiac, to lose,gain,or maintain weight,including Occupational,Physical,Speech,Massage without limitation: any weight control/loss Therapies and Spinal Manipulations categories program;appetite suppressants;dietary of the"What Is Covered?"section, regimens;food or food supplements;exercise Rehabilitative Therapies provided for the programs;equipment;whether or not It is part of purpose of maintaining rather than improving a treatment plan for a Condition. your Condition are also excluded. Wigs and/or cranial prosthesis. Reversal of Voluntary,Surgically-Induced Sterility including the reversal of tuba)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 Irked to nicotine withdrawal programs and nicotine products(e.g.,gum,lransdermal patches,etc.). Sports-Related devices and services used to affect performance primarily in sports-related Whet Is Not Covered? bS Section 4: Medical Necessity In order for Health Care Services to be covered 1. staying In the Hospital because under this Booklet,such Services must meet all arrangements for discharge have not been of the requirements to be a Covered Service, completed; Including being Medically Necessary,as defined 2. use of laboratory,x-ray,or other diagnostic by this Benefit Booklet. testing that has no clear indication,or is not It is important to remember that any review of expected to alter your treatment; Medical Necessity we undertake Is solely for the purposes of determining coverage,benefits,or 3. staying In the Hospital because supervision payment under the terms of this Booklet and not in the home,or care in the home,is not for the purpose of recommending or providing available or is inconvenient;or being medical care. In conducting a review of Medical hospitalized for any Service which could have been provided adequately in an Necessity, SCBSF may review specific medical facts or information pertaining to you. Any such alternate setting(e.g., Hospital outpatient department or at home with Home Health review,however.Is strictly for the purpose of Care Services):or determining whether a Health Care Service provided or proposed meets the definition of 4. inpatient admissions to a Hospital,Skilled Medical Necessity in this Booklet. In applying Nursing Facility,or any other facility for the the definition of Medical Necessity In this purpose of Custodial Care,convalescent Booklet to a specific Health Care Service, care,or any other Service primarily for the coverage and payment guidelines then in effect convenience of the patient or his or her may be applied by BCBSF. family members or a Provider. All decisions that require or pertain to Note: Whether or not a Health Care Service Independent professional medicapclinical is specifically listed as an exclusion,the fact Judgement or training,or the need for medical that a Provider may prescribe, recommend, services,are solely your responsibility and that approve,or furnish a Health Care Service of your treating Physicians and health care does not mean that the Service is Medically Providers. You and your Physicians are Necessary(as defined by this Benefit responsible for deciding what medical care Booklet)or a Covered Service. Please refer should be rendered or received and when that to the"Definitions"section for the care should be provided. Monroe County BOCC definitions of"Medically Necessary"or is ultimately responsible for determining whether "Medical Necessity". expenses incurred for medical care are covered under this Booklet. In making coverage decisions, neither BCBSF nor Monroe County BOCC will be deemed to participate in or override your decisions concerning your health or the medical decisions of your health care Providers. Examples of hospitalization and other Health Care Services that are not Medically Necessary include,but are not limited to: Medial Nac..* is Section 5: Understanding Your Share of Health Care Expenses This section explains what your share of the Benefits for the specific Covered Services which health care expenses will be far Covered are subject to a Copaymeni. Listed below is a Services you receive. In addition to the brief description of some of the Copayment information explained In this section, It is requirements that may apply to your plan. If the important that you refer to your Schedule of Allowed Amount or the Provider's actual charge Benefits to determine your share of the cost with for a Covered Service rendered is less than the regard to Covered Services. Copayment amount,you must pay the lesser of the Allowed Amount or the Provider's actual Deductible Requirement charge for the Covered Service. Individual Deductible 1. Office Services Copayment: This amount,when applicable,must be satisfied IF your plan is a Copayment plan,the by you and each of your Covered Dependents Copayment for Covered Services rendered in the office(when applicable)must be each Benefit Period,before any payment will be satisfied by you,For each office Service made by the Group Health Plan, Only those before any payment will be made. The charges Indicated on claims received for office Services Copayment applies Covered Services will be credited toward the regardless of the reason for the office visit individual Deductible and only up to the and applies to all Covered Services applicable Allowed Amount. Please see your rendered in the office,with the exception of Schedule of Benefits for more information. Durable Medical Equipment, Medical Family Deductible Pharmacy,Prosthetics,and Orthotics. If your plan Includes a family Deductible, alter Generally,if more than one Covered Service the family Deductible has been met by your that is subject to a Copayment is rendered family,neither you nor your Covered during the same office visit,you will be Dependents will have any additional Deductible responsible for a single Copayment which responsibility for the remainder of that Benefit will not exceed the highest Copayment Period. The maximum amount that any one specified in the Schedule of Benefits for the Covered Person In your family can contribute particular Health Care Services rendered. toward the family Deductible, if applicable,Is the 2. Inpatient Facility Copayment: amount applied toward the individual Deductible. Please see your Schedule of Benefits for more The inpatient facility Copayment must be Information. satisfied by you,for each inpatient admission to a Hospital,Psychiatric Facility, Copayment Requirements or Substance Abuse Facility,before any payment will be made for any claim for Covered Services rendered by certain Providers or at certain locations or settings will be subject inpatient Copaymente Services.es. The inpatient the applies regardless of the to a Copayment requirement. This is the dollar reason for the admission,and applies to all amount you have to pay when you receive these Inpatient admissions to a Hospital, Services, Please refer to your Schedule of Psychiatric Facility or Substance Abuse Understanding Your Share or Health tan Expenses 5.1 Facility in or outside the state of Florida. will still be responsible for the inpatient Additionally,you will be responsible for out- facility Copayment. of-packet expenses for Covered Services provided by Physicians and other health Hospital Per Admission Deductible care professionals for Inpatient admissions. The Hospital Per Admission Deductible(PAD) Note: Inpatient facility Copayments may must be satisfied by each Covered Plan vary depending on the facility chosen. Participant,for each Hospital admission,before (Please see the Schedule of Benefits for any payment will be made for any claim for more information). inpatient Health Care Services. The Hospital 3. Outpatient Facility Copayment: Per Admission Deductible applies regardless of the reason for the admission, is in addition to the The outpatient facility Copayment awctives Deductible requirement,and applies to all be satisfied by you,for each outpatient visit Hospital admissions in or outside the state of to a Hospital,Ambulatory Surgical Center, Florida. Independent Diagnostic Testing Facility, Psychiatric Facility or Substance Abuse Emergency Room Per Visit Facility,before any payment will be made for Deductible any claim for outpatient Covered Services. The Emergency Room Per Visit Deductible The Outpatient Facility Copayment applies (PVD)is set forth in the Schedule of Benefits. regardless of the reason for the visit,and The Emergency Room Per Visit Deductible applies to all outpatient visits to a Hospital, applies regardless of the reason for the visit, Is Psychiatric Facility or Substance Abuse in addition to the Deductible,and applies to Facility In or outside the state of Florida. emergency room services in or outside the state Additionally,you will be responsible for out- of Florida. The Emergency Room Per Visit of-pocket expenses for Covered Services Deductible must be satisfied by each Covered provided by Physician and other healthcare Plan Participant for each visit. If the Covered professionals. Plan Participant is admitted to the Hospital at the Note: Outpatient facility Copayments may time of the emergency room visit,the vary depending on the facility chosen. Emergency Room Per Visit Deductible will be (Please see the Schedule of Benefits for waived. more information). Coinsurance Requirements 4. Emergency Room Facility Copayment: All applicable Deductible or Copayment amounts The emergency room facility Copayment must be satisfied before any portion of the applies regardless of the reason for the visit, Allowed Amount will be paid for Covered is in addition to the applicable Coinsurance Services. For Services that are subject to amount,and applies to emergency room Coinsurance,the Coinsurance percentage of the facility Services in or outside the state of applicable Allowed Amount you are responsible Florida. The emergency room facility for is listed in the Schedule of Benefits. Copayment must be satisfied by you for each visit. If you are admitted to the Out-of-Pocket Maximums Hospital as an inpatient at the time of the emergency room visit,the emergency room individual out-of-pocket maximum facility Copayment will be waived,but you Once you have reached the individual out-of- pocket maximum amount listed in the Schedule Urdentahaing Your share of Heal Can Eapeesea 5-2 of Benefits,you will have no additional out-of- Booklet. This provision is only applicable for you pocket responsibility for the remainder of that during the initial Benefit Period of coverage Benefit Period and we will pay 100 percent of under this Benefit Booklet and the following the Allowed Amount for Covered Services rules apply: rendered during the remainder of that Benefit 1. Prior Coverage Credit for Deductible: Period. For[he initial Benefit Period of coverage Family out-of-pocket maximum under this Benefit Booklet only,charges If your plan includes a family out-of-pocket credited towards your Deductible maximum,once your family has reached the requirement under the prior policy or plan, family out-of-pocket maximum amount listed In for Services rendered during the 90-day the Schedule of Benefits,neither you nor your period immediately preceding the Effective covered family members will have any additional Date of the coverage under this Benefit out-of-pocket responsibility for the remainder of Booklet,will be credited to the Deductible that Benefit Period and we will pay 100 percent requirement under this Booklet. • of the Allowed Amount for Covered Services 2. Prior Coverage Credit for Coinsurance: rendered during the remainder of that Benefit Period. The maximum amount any one Covered Charges credited by Monroe County Person In your family can contribute toward the BOCC's prior policy or plan,towards your family out-of-pocket maximum,if applicable, Is Coinsurance Maximum,for Services the amount applied toward the individual out-of- rendered during the 90-day period pocket maximum. Please see your Schedule of Immediately preceding the Effective Date of Benefits for more Information. coverage under this Benefit Booklet,will be Noe:The Deductible,PAD,PVD,any credited to your out-of-packet maximum under this Booklet. applicable Copayments and Coinsurance amounts will accumulate toward the out-of- 3. Prior coverage credit towards the Deductible pocket maximums. My benefit penalty or out-of-pocket maximums will only be reductions,non-covered charges or any charges given for Health Care Services which would in excess of the Mowed Amount will not have been Covered Services under this accumulate toward the out-of-pocket maximums. Booklet. Prior Coverage Credit 4. Prior coverage credit under this Booklet only applies at the initial enrollment of the entire You will be given credit for the satisfaction or Group. You an&or Monroe County BOCC partial satisfaction of any Deductible and are responsible for providing BCBSF with Coinsurance maximums met by you under a any information necessary for BCBSF to prior group insurance,blanket insurance,or apply this prior coverage credit. franchise insurance or group Health Maintenance Organization(HMO)policy or plan Benefit Maximum Carryover maintained by Monroe County BOCC if the coverage provided hereunder replaces such a If immediately before the Effective Date of the policy or plan.This provision only applies If the coverage under this Benefit Booklet,you were prior group insurance,blanket Insurance, covered under a prior Monroe County BOCC franchise insurance, HMO or plan coverage was group plan Insured or administered by BCBSF, in effect immediately preceding the Effective amounts applied to your benefit maximums Dale of the coverage provided under this Benefit UndantanSog Your Share an Hob Cue Expenses 5-3 under the prior group plan,will be applied toward your benefit under this Booklet. Additional Expenses You Must Pay In addition to your share of the expenses described above, you are also responsible for: 1. any applicable Copayments; 2. expenses incurred for non-covered Services; 3. charges in excess of any maximum benefit limitation listed in the Schedule of Benefits (e.g.,the Benefit Period maximums); 4. charges in excess of the Allowed Amount for Covered Services rendered by Providers who have not agreed to accept the Allowed Amount as payment in full; 5. any benefit reductions; 6. payment of expenses for claims denied because we did not receive information requested from you regarding whether or not you-have other coverage and the details of such coverage; and 7. charges for Health Care Services which are excluded. Additionally,you are responsible for any contribution amount required by Monroe County BOCC. How Benefit Maximums Will Be Credited Only amounts actually paid for Covered Services MI be credited towards any applicable benefit maximums. The amounts paid which are credited-towards your benefit maximums will be based on the Allowed Amount for the Covered Services provided. Undenbndng Your Shan or Health Cam Expels*. 5< Section 6: Physicians, Hospitals and Other Provider Options Introduction continuing a relationship with a Family Physician It is important for you to understand how the allows the physician to become knowledgeable Provides you select end the setting in which you about you and your(amity's health history. A receive Health Care Services affects how much Family Physician can help you determine when you are responsible for paying under this You need to visit a specialist and also help you Booklet. This section, along with the Schedule find one based on their knowledge of you and of Benefits,describes the health care Provider your specific healthcare needs. Types of Family options available to you and the payment rules Physicians are Family Practitioners,General for Services you receive. Practitioners, internal Medicine doctors and Pediatricians. Additionally,care rendered by As used throughout this section soul-of-pocket Family Physicians usually results in lower out-of- expenses'.or"out-of-pocket'refers to the pocket expenses for you. Whether you select a amounts you are required to pay including any Family Physician or another type of Physician to applicable Copaymerds,the Deductible and/or render Health Care Services,please remember Coinsurance amounts for Covered Services. that using In-Network Providers may result In lower out-of-pocket expenses for you. You You are entitled to preferred provider type should always determine whether a Provider is benefits when you receive Covered Services In-Network or Out-of-Network prior to receiving from In-Network Providers. You are entitled to Services to determine the amount you are traditional program type benefits at the point of responsible for paying out-of-pocket. service when you receive Covered Services from Traditional Program Providers or BlueCard Location of Service (Out-of-State)Traditional Program Providers,in conformity with Section 7: BlueCard(Out-of- In addition to the participation status of the State)Program. Provider,the location or setting where you receive Services can affect the amount you pay. Provider Participation Status For example, the amount you are responsible for paying out-of-pocket will vary whether you With BlueOptions,you may choose to receive receive Services in a Hospital,a Provider's Services from any Provider. However,you may office,or an Ambulatory Surgical Center. be able to lower the amount you have to pay for Please refer to your Schedule of Benefits for Covered Services by receiving care from an In- specific information regarding your out-of-pocket Network Provider. Although you have the option expenses for such situations. After you and to select any Provider you choose,you are your Physician have determined the plan of encouraged to select and develop a relationship treatment most appropriate for your care,you with an In-Network Family Physician. There are should refer to the*What Is Covered?section several advantages to selecting a Family and your Schedule of Benefits to find out if the Physician. Family Physicians are trained to specific Health Care Services are covered and provide a broad range of medical care and can how much you will have to pay. You should also be a valuable resource to coordinate your consult with your Physician to determine the overall healthcare needs. Developing and most appropriate setting based on your health care and financial needs. PhysiW,q Hospitals and Other Provider op�anf 6r To verify if a Provider is In-Network for your plan you can: 1. If in Florida, review your current BlueOptions Provider Directory; 12. If in Florida,access the BlueOptions Provider directory at BCBSF's web-site at ynvw.toddablue.corm;angler 3. If outside of Florida,access the on-line BlueCard Doctor and Hospital Finder at www toridablue.com;and/or I 4. Call the customer service phone number In this Booklet or on your Identification Card to search for PPO providers. I Please remember that changes to Provider network partidpaton can occur at any time. Consequently,it is your responsibility to determine whether a specific Provider is In- Network at the time you receive Covered Services. In-Network Providers When you use In-Network Providers,your out- of-pocket expenses for Covered Services may be lower. Payment will be based on the Mowed Amount and your share of the cost will be at the In-Network benefit level listed in the Schedule of Benefits. Out-of-Network Providers When you use Out-of-Network Providers your out-of-pocket expenses for Covered Services will be higher. We will base our payment on the Allowed Amount at the Coinsurance percentage listed in the Schedule of Benefits. Further, if the Out-of-Network Provider is a Traditional Program-Provider or a BlueCard(Out-of-State) Traditional Program Provider,our payment to such Provider may be under the terms of that Provider's contract. If your Schedule of Benefits and BlueOptions Provider directory do not 4Ifelude a Provider as In-Network under your benefit plan,the Provider is considered Out-of- Network. Physicians.Hopliala end Other Provide Options 6-2 In-Network Out-of-Network What expenses • Any applicable Copayments, Deductible(s)and/or Coinsurance requirements; are you • Expenses for Services which are not covered; responsible for • Expenses for Services in excess of any benefit maximum limitations; paying? • Expenses for claims denied because we did not receive information requested from you regarding whether or not you have other coverage and the details of such coverage;and • Expenses for Services which are excluded. Who is • The Provider will file the claim • You are responsible for filing the responsible for for you and payment will be claim and payment will be made filing your made directly to the Provider. directly to the Covered Plan claims? Participant. If you receive Services from a Provider who participates In our Traditional Program or is a BlueCard(Out-of-State)Traditional Program Provider,the Provider will file the claim for you. In those Instances payment will be made directly to the Provider. Can you be billed • NO. You are protected from • YES. You are responsible for paying the difference being blued for the difference in the difference between what we pay - between what the the Allowed Amount and the and the Providers charge. However, Provider is paid Providers charge when you use if you receive Services from a and the Provider's In-Network Providers. The Provider who participates in our charge? Provider will accept the Allowed Traditional Program,the Provider will Amount as payment in full for accept ow Allowed Amount as Covered Services except as payment In full for Covered Services otherwise permitted under the since such Traditional Program terms of the Provider's contract Providers have agreed not to bill you and this Booklet. for the difference, Further,under the BlueCard(Quid-State)Program, when you receive Covered Services from a BlueCard(Out-of-Slate) Traditional Program Provider, you may be responsible for paying the difference between what the Host --__---- Blue pays and the Providers billed charge. Note; You are solely responsible for selecting a Provider when obtaining Health Care Services and for verifying whether that Provider is In-Network or Out-of-Network. You are also responsible for determining the corresponding payment options, If any,at the time the Health Care Services are rendered. PhyskWi.Hospitals and Other Pm**Opaam 6.3 Physicians admits to by contacting the Physician's office. This will provide you with information that will When you receive Covered Services from a help you determine a portion of what your out-of- Physician you will be responsible far a pocket costs may be in the event you are Copayment and/or the Deductible and the hospitalized. applicable Coinsurance. Several factors wiU Refer to your Schedule of Benefits to determine determine your out expenses including the applicable out-of-pocket expenses you are your Schedule of Benefits,enefits,whether hether the Physician is In-Network or Out-of-Network,the responsible for paying for Hospital Services. location of service,the type of Service rendered, Specialty Pharmacy and the Physician's specialty. Remember that the location or setting where a Certain medications,such as injectable,oral, Service is rendered can affect the amount you inhaled and Infused therapies used to treat are responsible far paying out-of-pocket. After complex medical Conditions are typically more you and your Physician have determined the difficult to maintain,administer and monitor plan of treatment most appropriate for your care, when compared to traditional Drugs. Specialty you should refer to the Schedule of Benefits and Drugs may require frequent dosage consult with your Physician to determine the adjustments,special storage and handling and most appropriate setting based on your health may not be readily available at local pharmacies care and financial needs. or routinely stocked by Physicians'offices, Refer to your Schedule of Benefits to determine mostly due to the high cost and complex the applicable Copayments,Coinsurance handling they require. percentage and/or Deductible amount you are Using the Specialty Pharmacy to provide these responsible for paying for Physician Services. Specialty Drugs should lower the amount you have to pay for these medications,while helping Hospitals to preserve your benefits. Each time you receive inpatient or outpatient Other Providers Covered Services at a Hospital,in addition to any out-of-pocket expenses related to Physician With BlueOptions you have access to other Services,you will be responsible for out-of- Providers in addition to the ones previously pocket expenses related to Hospital Services. described in this section. Other Providers In-Network Hospitals have been divided into two include facilities that provide alternative groups that are referred to as"options"on the outpatient settings or other persons and entities Schedule of Benefits. The amount you are that specialize in a specific Service(s). While responsible for paying out-of-pocket is different these Providers may be recognized for payment, for each of these options. Remember that there they may not be included as In-Network are also different out-of-pocket expenses for Providers for your plan. Additionally,all of the Out-of-Network Hospitals. Services that are within the scope of certain Providers'licenses may not be Covered Since not all Physicians admit patients to every Services under this Booklet. Please refer to the Hospital,it is Important when choosing a 'What Is Covered?and"What Is Not Covered? Physician that you determine the Hospitals sections of this Booklet and your Schedule of where your Physician has admitting privileges. Benefits to determine your out-of-pocket You can find out what Hospitals your Physician Physicians,Hospitals and Ogler Provider Options 6J expenses for Covered Services rendered by 4)is a BlueCard(Out-of-State)PPO Program these Providers. Provider;5)is a BlueCard(Out-of-Slate) You may be able to receive certain outpatient Traditional Program Provider;8)Is a licensed Services at a location other than a Hospital. The Hospital, Physician,or dentist and the benefits amount you are responsible for paying for which have been assigned are for care provided Services rendered at some alternative facilities pursuant to section 395.1041,Florida Statures is generally less than If you had received those or 7)Is an Ambulance Provider that provides same Services at a Hospital. transportation for Services from the location where an"emergency medical condition', Remember that the location of service can defined in section 395.002(8)Florida Statutes, impact the amount you are responsible for first occurred to a Hospital,end the benefits paying out-of-pocket. After you and your which have been assigned are for transportation Physician have determined the plan of treatment to care provided pursuant to section 395.1041, most appropriate for your care,you should refer Florida Statutes. A written attestation of the to the Schedule of Benefits and consult with assignment of benefits may be required. your Physician to determine the most appropriate setting based on your health care and financial needs. When Services are rendered at an outpatient facility other than a Hospital there may be an out-of-pocket expense for the facility Provider as well as an out-of- pocket expense for other types of Providers. Assignment of Benefits to Providers Except as set forth in the last paragraph of this section,any of the following assignments,or attempted assignments, by you to any Provider will not be honored: • an assignment of the benefits due to you for Covered Services under this Benefit Booklet; • an assignment of your right to receive payments for Covered Services under this Benefit Booklet;or • an assignment of a claim for damage resulting from a breach,or an alleged --breach of the terms of this Benefit Booklet. We specifically reserve the right to honor an assignment of benefits or payment by you to a Provider who: 1)is In-Network under your plan of coverage;2)Is a NetworkBlue Provider even If that Provider is not in the panel for your plan of coverage;3)Is a Traditional Program Provider, Phyfk4nr,Hospitals end ONerPmNder Optas 6.5 Section 7: BlueCard®(Out-of-State) Program Out-of-Area Services • The negotiated price That the Host Blue We have a variety of relationships with other makes available to us. Blue Cross and/or Blue Shield Licensees Often,this'negotiated price'will be a simple referred to generally as'Inter-Plan Programs'. discount that reflects an actual price that the Host Whenever you obtain Health Care Services Blue pays to your health care Provider. outside of our service area,the claims For these Sometimes, it is an estimated price that takes into Services may be processed through one of account special arrangements with your health these Inter-Plan Programs,which include the care Provider or Provider group that may include BlueCard Program and may Include negotiated types of settlements,Incentive payments,and/or National Account arrangements available other credits or charges. Occasionally,it may be between us and other Blue Cross and Blue an average price,based on a discount that Shield Licensees. results in expected average savings for similar Typically,when accessing care outside our types of health care Providers after taking into service area,you will obtain care from health account the same types of transactions as with care Providers that have a contractual an estimated price. agreement(I.e.,are'participating providers") Estimated pricing and average pricing,going with the local Blue Cross and/or Blue Shield forward,also lake Into account adjustments to Licensee In that other geographic area('Host correct for over-or underestimation of Blue"). In some instances,you may obtain care modifications of past pricing for the types of from non-participating health care Providers. transaction modifications noted above. However, Our payment practices In both instances are such adjustments will not affect the price we use described below. for your claim because they will not be applied retroactively to claims already paid. BlueCard Program Laws In a small number of states may require the Under the BlueCard Program,when you Host Blue to add a surcharge to your calculation. access Covered Services within the geographic If any state laws mandate other liability area served by a Host Blue,we will remain calculation methods,Including a surcharge,we responsible for fulfilling our contractual would then calculate your liability for any Covered obligations. However,the Host Blue is Services according to applicable law. responsible(or contracting with and generally handling all interactions with its participating Out-of-Network Providers Outside Our health care Providers. Service Area Whenever you access Covered Services Your Liability Calculation outside our service area end the claim Is When Covered Services are provided outside of processed through the BlueCard Program,the our service area by non-participating health care amount you pay for Covered Services is calculated based on the lower of: Providers,the payment will be based on the Allowed Amount as defined in the Benefit • The billed covered charges for your Booklet. Covered Services:or e leCad(OamlSur•1 PPgmm r,n Section 8: Blueprint for Health Programs Introduction Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility(as applicable)if we BCBSF has established(and from time to time have been notified of your admission. For an establishes)various customer-focused health admission outside of Florida,you or the education and information programs as well as Hospital,Psychiatric Facility Substance Abuse benefit utilization management and utilization review programs.Under the terms of the ASO Facility or Skilled Nursing Facility(as applicable) Agreement between BCBSF and Monroe should notify us of the admission. Making sure County BOCC, BCBSF has agreed to make that we are notified of your admission will enable these programs available to you.These us to provide you information about the Blueprint programs,collectively called the Blueprint for for Health Programs available to you. You or Health Programs,are designed to 1)provide you the Hospital.Psychiatric Facility, Substance with information that will help you make more Abuse Facility or Skilled Nursing Facility(as informed decisions about your health,2)help applicable)may notify us of your admission by facilitate the management and review of calling the toll free customer service number on coverage and benefits provided under this your ID card. Booklet and 3)present opportunities,as explained below,to mutually agree upon Out-of-Network alternative benefits or payment alternatives for cost-effective medically appropriate Health Care For admissions to an Out-of-Network Hospital, Services. Some Blueprint For Health Psychiatric Facility, Substance Abuse Facility or Programs may not be available outside the Skilled Nursing Facility,you or the Hospital, state of Florida. Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility should notify BCBSF of Admission Notification the admission. Notifying BCBSF of your admission will enable BCBSF to provide you The admission notification requirements vary information about the Blueprint for Health depending on whether you are admitted to a Programs available to you. You or the Hospital Hospital,Psychiatric Facility,Substance Abuse may notify BCBSF of your admission by calling Facility or Skilled Nursing Facility which is In- the toll-free customer service number on your ID Network or Out-of-Network. card. In-Network Inpatient Facility Program Under the admission notification requirement, Under the inpatient facility program,we may we must be notified of all Inpatient admissions review Hospital stays, Hospice, Inpatient (i.e.,elective,planned,urgent or emergency)to Rehabilitation,LTAC and Skilled Nursing Facility In-Network Hospitals, Psychiatric Facilities, (SNF)Services,and other Health Care Services Substance Abuse Facilities or Skilled Nursing rendered during the course of an inpatient stay Facilities. While It is the sole responsibility of or treatment program. We may conduct this the In-Network Provider located In Florida to review while you are inpatient,after your compty with our admission notification discharge,or as part of a review of an episode requirements,you should ask the Hospital, of care when you are transferred from one level OFapnrg foe Heal Programs &1 of inpatient care to another for ongoing required under the terms of their agreement treatment. The review is conducted solely to with us;or determine whether we should provide coverage 2 we perform a focused review under the and/or payment for a particular admission or focused utilization management Health Care Services rendered during that g program admission. Using our established criteria then In and we determine that a Health Care effect,a concurrent review of the inpatient stay Service Is not Medically Necessary in may occur at regular intervals,including In accordance with our Medical Necessity advance of a transfer from one Inpatient facility criteria or inconsistent with our benefit guidelines then in effect unless the following to another. We will provide notification to your exception applies. Physician when inpatient coverage criteria are no longer met. In administering the inpatient Exception for Certain NetworkBlue Physicians facility program,we may review specific medical Certain NetworkBlue Physicians licensed as facts or information and assess,among other Doctors of Medicine(M.D.)or Doctors of things,the appropriateness of the Services Osteopathy to be onlyf may bill you for Sryrbices being rendered,health care setting sootier the determined lobe not Medically Necessary by level of care of an inpatient admission or other BCBSF under this focused utilization health care treatment program. My such management program if,before you receive the reviews by us,and any reviews or assessments Service: of specific medical facts or information which we conduct,are solely for purposes of making a. they give you a written estimate of your coverage or payment decisions under this financial obligation for the Service; Benefit Booklet and not for the purpose of b. they specifically identify the proposed recommending or providing medical care. Service that BCBSF has determined not to be Medically Necessary;and Provider Focused Utilization Management Program c. you agree to assume financial responsibility for such Service. Certain NetworkBlue Providers have agreed to participate in our focused utilization Prior Coverage Authorization/Pre- management program. This preservice review Service Notification Programs program is intended to promote the efficient delivery of medically appropriate Health Care It Is important for you to understand our prior Services by NetworkBlue Providers. Under this coverage authorization programs and how the program we may perform focused prospective Provider you select and the type of Service you reviews of all or specific Health Care Services receive affects these requirements and proposed for you. In order to perform the ultimately how much you are responsible for review,we may require the Provider to submit to paying under this Benefit Booklet. us specific medical Information relating to Health You or your Provider will be required to obtain Care Services proposed for you. These prior coverage authorization from us for: NetworkBlue Providers have agreed not to bill, or collect,any payment whatsoever from you or1. advanced diagnostic imaging Services, us,or any other person or entity,with respect to such as CT scans,MRis,MRA and nuclear a specific Health Care Service if: Imaging; 1. they fall to submit the Health Care Service fora focused prospective review when Blueprint rcr Haan Programs g.g 2. Autism Spectrum Disorder;Mental customer service phone number on the back Health;and Substance Dependency of your ID Card. Services;and 2. In the case of Autism Spectrum Disorder, 3. other Health Care Services that are or may Mental Health,and Substance become subject to a prior coverage Dependency Services under a prior authorization program or a pre-service coverage authorization or pre-service notification program as defined and notification program,It is your sole administered by us, responsibility to comply with our prior Prior coverage authorization requirements vary, coverage authorization or pre-service depending on whether Services are rendered by notification requirements when rendered or an In-Network Provider or an Out-of-Network referred by an Out-of-Network Provider, Provider,as described below: before the Services are provided. Failure to obtain prior coverage authorization In-Network Providers will result in denial of coverage for such It is the In-Network Provider's sole responsibility Services. to comply with our prior coverage authorization 3. In the case of other Health Care Services requirements,and therefore you will not be under a prior coverage authorization or pre- responsible for any benefit reductions If prior service notification program,It is your sole coverage authorization is not obtained before responsibility to comply with our prior Medically Necessary Services are rendered. coverage authorization or pre-service Once we have received the necessary medical notification requirements when rendered or documentation from the Provider,we will review referred by an Out-of-Network Provider, thelnformation and make a prior coverage before the Services are provided. Failure authorization decision,based on our established to obtain prior coverage authorization or criteria then in effect. The Provider will be provide pre-service notification may notified of the prior coverage authorization result In denial of the claim or application decision, of a financial penalty assessed at the Out-of-Network Providers time the claim is presented for payment to us. The penalty applied will be the lesser 1. In the case of advanced diagnostic of$500 or 20%of the total Allowed Amount Imaging Services such as CT scans, MRIs, of the claim. The decision to apply a penalty MRA and nuclear imaging,it is your sole or deny the claim will be made uniformly and responsibility to comply with our prior coverage authorization requirements when will be Identified in the notice describing the rendered or referred by an Out-of-Network prior coverage authorization and pre-service Provider before the advanced diagnostic notification programs. Imaging Services are provided. Your Once the necessary medical documentation has failure to obtain prior coverage been received from you and/or the Out-of- authorization will result in denial of Network Provider,BCBSF or a designated coverage for such Services, vendor,will review the information and make a For additional details on how to obtain prior prior coverage authorization decision,based on coverage authorization for advanced our established criteria then in effect. You will diagnostic imaging Services,please call the be notified of the prior coverage authorization decision. Blueprint lor Health rucgrama s-r BCBSF will provide you information for any Out- made available on a case-by-case basis when of-Network Health Care Service subject to a you meet BCBSF's case management criteria prior coverage authorization or pre-service then in effect. Such alternative benefits or notification program,including how you can payments,if any,will be made available in obtain prior coverage authorization and/or accordance with a treatment plan with which provide the pre-service notification for such you,or your representative,and your Physician Service not already listed here. This information agree to in writing. In addition,Monroe County will be provided to you upon enrollment,or at BOCC will be required to specifically agree to least 30 days prior to such Out-of-Network such treatment plan and the alternative benefits Services becoming subject to a prior coverage or payment. authorization or pre-service notification program. The fact that certain Health Care Services under See the-Claims Processing°section for the personal case management program have Information on what you can do if prior coverage been provided or payment has been made in no way obligates BCBSF, Monroe County BOCC, authorization is denied. or the Group Health Plan to continue to provide Note: Prior coverage authorization Is not or pay for the same or similar Services. Nothing required when Covered Services are provided contained in this section shall be deemed a for the treatment of an Emergency Medical waiver of Monroe County BOCC's right to Condition. enforce this Booklet in strict accordance with its Member Focused Programs terms. The terms of this Booklet will continue to apply,except as specifically modified In writing I The Blueprint for Health Programs may include in accordance with the personal case voluntary programs for certain members. These management program rules then In effect. programs may address health promotion, prevention and early detection of disease. chronic illness management programs,case management programs and other member focused programs. Personal Case Management Program The personal case management program focuses on members who suffer from a catastrophic illness or injury. In the event you have a catastrophic or chronic Condition,we may,in BCBSF's sole discretion,assign a Personal Case Manager to you to help coordinate coverage,benefits,or payment for Health Care Services you receive. Your participation in this program is completely voluntary. I Under the personal case management program, you may be offered alternative benefits or payment for cost-effective Health Care Services. These alternative benefits or payments may be emew ran Health Pmeans B4 Health Information,Promotion,Prevention and Illness Management Programs I These Blueprint for Health Programs may include health information that supports health care education and choices for healthcare issues. These programs focus on keeping you well,help to identify early preventive measures of treatment and help covered individuals with chronic problems to enjoy lives that are as productive and healthy as possible. These programs may Include prenatal educational programs and illness management programs for Conditions such as diabetes,cancer and heart disease. These programs are voluntary and are designed to enhance your ability to make Informed choices and decisions for your unique health care needs. You may call the toll free customer service number on your ID card for more information. Your participation In this prooram Is completely voluntary. I IMPORTANT INFORMATION RELATING TO BCBSF'S BLUEPRINT FOR HEALTH PROGRAMS I All decisions that require or pertain to independent professional medicaUclinical Judgment or training,or the need for medical services,are solely your responsibility and the responsibility of your Physicians and other health care Providers. You and your Physicians are responsible for deciding what medical care should be rendered or received,and when and how that care should be provided. Monroe County SOCC Is ultimately responsible for determining whether expenses,which have been or will be incurred for medical care are,or will be,covered under this Booklet. In fulfilling this responsibility,neither BCBSF nor Monroe Cluny-BOCC will be deemed to participate in or override the medical decisions of your health care Provider. Please note that the Hospital admission notification requirement and any Blueprint For Health Program may be discontinued or modified at any time without notice to you or your consent. Bluepna for Hera Programs 15 I Section 9: Eligibility for Coverage Each employee or other individual who Is eligible Note: Employees end qualified Dependents are to participate in the Monroe County Group eligible for coverage on the day following Health Plan,and who meets and continues to the 601"day of continuous service or meet the eligibiky requirements described in this Waiting Period. Booklet,shall be entitled to apply for coverage Monroe County BOCC's coverage eligibility under this Booklet. These eligibility classifications may be expanded to include: requirements are binding upon you and/or your eligible family members. No changes in the 1. retired employees; eligibility requirements wet be permitted except 2. additional iob classifications' as permitted by Monroe County BOCC. 2, 3. Constitutional Officers or their Acceptable documentation may be required as Employees; proof that an individual meets and continues to meet the eligibility requirements such as a court g *IdilieaaijekclasslGeetieoet order naming the Eligible Employee as the legal 4, 4. employees of affiliated or subsidiary guardian or appropriate adoption documentation companies of Monroe County BOCC;and described in the"Enrollment and Effective Date of Coverage"section. 6. 5_other individuals as determined by Monroe County BOCC. I Eligibility Requirements for Covered Monroe County BOCC shall have sole discretion Pian Participants concerning the expansion of eligibility classifications. In order to be eligible to enroll as a Covered Plan Participant,an individual must be an Eligibility Requirements for Eligible Employee or Eligible Retiree. An Dependent(s) Eligible Employee must meet each of the following requirements: An individual who meets the eligibility criteria specified below is an Eligible Dependent and is 1. The employee must be a bona fide eligible to apply for coverage under this Booklet: employee of a Monroe County Employer, participating in the Monroe County Group 1. The Covered Plan Participant's spouse Health Plan; under a legally valid existing mariagem 2. The employee must be actively working 25 defined under FedereiFlortda Law. hours or more per week on a regular basis; 2. The Covered Plan Participant's natural, J_ The employee must have completed the newborn,adopted,Foster,or step chlld(ren) applicable Waiting Period of 60 days of (or a child for whom the Covered Plan continuous service;and Participant has been court appointed as 4. The employee legal guardian or legal custodian)who has p yee must meet any additional not reached the end of the Calendar Year in eligibility requirement(s)required by Monroe which he or she reaches age 26(or in the County BOCC' case of a Foster Child,is no longer eligible under the Foster Child Program),regardless ErgeayFcc Coverage 9-1 of the dependent child's student or marital This eligibility shall terminate on the last day of status,financial dependency on the Covered the Calendar Year in which the dependent child Plan Participant,whether the dependent reaches age 30. child resides with the Covered Plan Handicapped Children Participant,or whether the dependent child is eligible for or enrolled In any other group In the case of a handicapped dependent child, health plan. such child is eligible to continue coverage as a Covered Dependent,beyond the age of 26, if 3. The newborn child of a Covered Dependent the child is: child who has not reached the end of the Calendar Year in which he or she becomes 1• otherwise eligible for coverage under the 26. Coverage for such newborn child will Group Health Plan: automatically terminate 18 months after the 2. Incapable of self-sustaining employment by birth of the newborn child. reason of mental retardation or physical Note: If a Covered Dependent child who has handicap;and reached the end of the Calendar Year in which 3. chiefly dependent upon the Covered Plan he or she becomes 26 obtains a dependent of Participant for support and maintenance their own(e.g.,through birth or adoption)such provided that the symptoms or causes of the newborn child will not be eligible for this child's handicap existed prior to the child's coverage and the Covered Dependent child will 2614 birthday. also lose his or her eligibility for this coverage. It This eligibility shall terminate on the last day of is the Covered Plan Participant's sole the month in which the dependent child no responsibility to establish that a child meets the anger meets the requirements for extended applicable requirements for eligibility. eligibility as a handicapped child. This eligibility shall terminate on the last day or Exception for Students on Medical Leave of the Calendar Year In which the dependent child Absence from School reaches age 26. Extension of Eligibility for Dependent A Covered Dependent child who is a full-time or Children part-time student at an accredited post- secondary institution,who takes a physician A Covered Dependent child may continue certified medically necessary leave of absence coverage beyond the end of the Calendar Year from school,will still be considered a student for in which he or she reaches age 26,provided he eligibility purposes under this Booklet for the or she is: earlier of 12 months from the Mt day of the 1. unmarried and does not have a dependent; leave of absence or the date the Covered Dependent would otherwise no longer be eligible 2. a Florida resident or a full-time or part-time for coverage under this Booklet. student; 3. not enrolled in any other health coverage policy or group health plan;and 4. not entitled to benefits under Title XVIII of the Social Security Act unless the child is a handicapped dependent child. Ergita*For Coverage 9.2 Section 10: Enrollment and Effective Date of Coverage Eligible Employee, Eligible Retirees and Employee/Retiree and the employee's spouse Eligible Dependents may enroll for coverage under a legally valid existing marriage under according Io the provisions below. Federal Law or Domestic Partner. Any Eligible Employee, Eligible RetiresRetirees EmployeefChild(ren)Coverage-This type of or Eligible Dependent who is not properly coverage provides coverage for the enrolled will not be covered under this Benefit Employee/Retiree and the covered child(ren) Booklet. Neither BCBSF nor Monroe County only. BOCC will have any obligation whatsoever to EmployeelFamily Coverage-This type of any individual who is not properly enrolled. coverage provides coverage for the My Employee,Eligible Retiree?Retirees or Employee/Retiree and the or Eligible Retiree Eligible Dependent who is eligible for coverage Covered Dependents. under this Booklet may apply for coverage There may be additional contribution amounts according to the provisions set forth below. for each Covered Dependent based on the coverage selected by Monroe County BOCC. Enrollment Forms/Electing Coverage Enrollment Periods To apply for coverage,you as the Eligible Employee or Eligible Retiree must: The enrollment periods for applying for coverage 1. complete and submit,through Monroe are as follows: County BOCC Benefits Office,the Initial Enrollment Period is the period of time Enrollment Form; during which an Eligible Employee or Eligible 2. provide any additional information needed to Dependent is first eligible to enroll. It starts on determine eligibility, at the request of the Eligible Employee's or Eligible Dependent's BCBSF or Monroe County BOCC Benefits initial date of eligibility and ends no less than 30 Office; days later. 3. pay any required contribution;and Annual Open Enrollment Period Is the period of time during which each Eligible Employee or 4. complete and submit,through Monroe Eligible Retiree is given an opportunity to select County BOCC Benefits Office,an coverage from among the alternatives included Enrolment Form to add Eligible in Monroe County BOCC's health benefit Dependents. program. The period Is established by Monroe When making application for coverage,you County BOCC,occurs annually,and will take must elect one of the types of coverage place when specified by Monroe County BOCC. available under Monroe County BOCC's Spacial Enrollment Period is the 30-tlay period program. Such types may include: of time(unless otherwise noted)Immediately Employee Only Coverage-This type of following a special circumstance during which an coverage provides coverage for the Eligible Employee or Eligible Dependent may Employee/Retiree only. apply for coverage. Special circumstances are I Employee/Spouse Coverage-This type of described In the Special Enrollment Period coverage provides coverage for the subsection. Enrollment and Effete Date of Coverage 104 Employee Enrollment Enrollment Period,or In the case of a Special Enrollment event,during the Special Enrollment An Eligible Employee who fags to enroll during Period. the Initial Enrollment Period will not be covered and may only enroll under this Benefit Booklet Note: For a Covered Dependent child who has during the next Annual Open Enrollment Period he reached the end of the Calendar Year in which established by Monroe County BOCC,or In the or she becomes a and the ndent tl case of a Special Enrollment event,during the Dependent child obtains a Dependent of their ownSpecial Enrollment Period. The Effective Date newborn(e.g.,through birth or adoption),gible( such will be the date specified by Monroe County child will not be eligible for this BOCC. coverage and cannot enroll. Further, such Covered Dependent child will also lose his or Dependent Enrollment her eligibility for this coverage. Adopted Newborn Child—To enroll an An individual may be added upon becoming an adopted newborn child,the Covered Plan Eligible Dependent of a Covered Plan Participant must submit an Enrollment Form Participant. Below are special rules for certain through Monroe County BOCC Benefits Office to Eligible Dependents. BCBSF during the 30-day period Immediately following the date of bkth. The Effective Date of I Newborn Child—To enroll a newborn child who Is an Eligible Dependent,the Covered Plan coverage for an adopted newborn child,eligible Participant must submit an Enrollment Form to for coverage,will be the moment of birth, BCBSF through Monroe County BOCC Benefits provided that a written agreement to adopt such Office during the 30•day period Immediately child has been entered into by the Covered Plan following the date of birth. The Effective Date of Participant prior to the birth of such child, coverage for a newborn child will be the date of w or not such an agreement Is birth, enfforceorce able. The Covered Plan Participant may be required to provide any information and/or I If timely notice is given,no additional documents that are deemed necessary In order contribution will be charged for coverage of the to administer this provision. newborn child for not less than 30 days after the If timely notice is given,no additional birth of the child. If timely notice is not received, contribution will be charged for coverage of the the applicable contribution will be charged from adopted newborn child for not lass than 30 days the date of birth. The applicable contribution for after the birth of the child. If timely notice is not the child will be charged after the initial 30-day received,the applicable contribution will be period in either case. Coverage will not be charged from the date of birth. The applicable denied for a newborn child if the Covered Plan contribution for the child will be charged after the Participant provides notice to Monroe County initial 30-day period in either case. Coverage BOCCBenefits Office and an Enrollment Form will not be denied for an adopted newborn child Is received within the 60-day period of the birth if the Covered Plan Participant provides notice of the child and any applicable contribution is to Monroe County BOCC Benefits Office and an paid back to the date of birth. Enrolknent Form is received within the 60-day If the newborn is not enrolled within sixty days of period of the birth of the adopted newborn child the date of birth,the newborn child will not be and any applicable contribution is paid back to covered,and may only be enrolled under this the date of birth. Benefit Booklet during an Annual Open error ee en0eaxtie DateofCowrage iP! If the adopted newborn child is not enrolled issued,coverage shall not be continued for the within sixty days of the date of birth,the adopted proposed adopted Child. Proof of final adoption newborn child will not be covered,and may only must be submitted to BCBSF through Monroe be enrolled under this Benefit Booklet during an County BOCC Benefits Office. It Is the Annual Open Enrollment Period,or In the case responsibility of the Covered Plan Participant to of a Special Enrollment event,during the Special notify BCBSF through Monroe County BOCC Enrollment Period. Benefits Office if the adoption does not take If the adopted newborn child is not ultimately place. Upon receipt of this notification,we will placed in the residence of the Covered Plan terminate the coverage of the child as of the Participant,there shall be no coverage for the Effective Date of the adopted child upon receipt adopted newborn child. It is your responsibility of the written notice. as the Covered Plan Participant to notify Monroe If the Covered Plan Participant's status as a County BOCC Benefits Office within len foster parent is terminated, coverage will end for calendar days of the date that placement was to any Foster Chad. It is the responsibility of the occur if the adopted newborn child is not placed Covered Plan Participant to notify BCBSF in your residence. through Monroe County BOCC Benefits Office Adopted/Foster Children—To enroll an that the Foster Child is no longer In the Covered adopted or Foster CMId,the Covered Plan Plan Participants care. Upon receipt of this Participant must submit an Enrollment Form notification,coverage for the child will be during the 30-day period Immediately following terminated on the date the Covered Plan the date of placement. The Effective Date for an Participants status as a foster parent adapted or Foster child(other than an adopted terminated. newborn child)will be the date such adopted or Marital Status—The Covered Plan Participant Foster child is placed In the residence of the may apply for coverage of an Eligible Dependent ICovered Plan Participant in compliance with due to a legally valid existingpag marriage applicable law. The Covered Plan Participant as defined under Federa¢Inrida Law. To apply may be required to provide any Information for coverage,the Covered Plan Participant must and/or documents deemed necessary in order to complete the Enrollment Form through Monroe properly administer this section. County BOCC Benefits Office and forward it to In the event Monroe County BOCC Benefits BCBSF. The Covered Plan Participant must Office is not notified within 30 days of the date of make application for enrollment within 30 days placement,the child will be added as of the date of the marriage. The Effective Date of coverage of placement so long as Covered Plan for an Eligible Dependant who Is enrolled as a Participant provides notice to Monroe County result of marriage is the date of the marriage. BOCC Benefits Office,and we receive the Court Order—The Covered Plan Participant Enrollment Form within 60 days of the may apply for coverage for an Eligible placement. If the adopted or Foster Child is not Dependent outside of the Initial Enrollment enrolled within sixty days of the date of Period and Annual Open Enrollment Period If a placement,the adopted or Foster Child will not court has ordered coverage to be provided for a be covered,and may only be enrolled under this minor child under their group coverage. To Benefit Booklet during an Annual Open apply for coverage,the Covered Plan Participant Enrollment Period,or in the case of a Special must complete an Enrollment Farm through Enrollment event,during the Special Enrollment Monroe County BOCC Benefits Office and' Period.For all children covered as adopted forward it to BCBSF. The Covered Plan children,If the final decree of adoption is not Participant must make eppllcaton for enrollment Enrollment and Effective Data or Coverage 163 I within 30 days of the court order. The Effective L If you lose your coverage under another Date of coverage for an Eligible Dependent who group health benefit plan(as an employee is enrolled as a result of a court order is the date or dependent),or coverage under other required by the court. health insurance(except in the case of loss of coverage under a Children's Health Annual Open Enrollment Period Insurance Program(CHIP)or Medicaid,see e3 below),or COBRA continuation Eligible Employees and/or Eligible Dependents coverage that you were covered under at who did not apply for coverage during the Initial the time of Initial enrollment provided that: I Enrollment Period or a Special Enrollment a) when offered coverage under this plan Period may apply for coverage during an Annual et the time of initial eligibility,you slated, Open Enrollment Period. The Eligible Employee in writing,that coverage under a group may enroll by completing the Enrollment Form health plan or health insurance during the Annual Open Enrollment Period. coverage was the reason for declining The effective date of coverage for an Eligible enrollment;and Employee and any Eligible Dependent(s)will be b) you lost your other coverage under a the date established by Monroe County BOCC group health benefit plan or health Benefits Office. Insurance coverage(except In the case Eligible Employees who do not enroll or change of loss of coverage under a CHIP or their coverage selection during the Annual Open Medicaid,see a belowe) es a result of Enrollment Period, must wait until the next lamination of employment reduction in the number of hours you work,reaching Annual Open Enrollment Period,unless the or exceeding the maximum lifetime of all Eligible Employee or the Eligible Dependent is benefits under other health coverage, enrolled due to a special circumstance as the employer ceased offering group outlined In the Special Enrollment Period health coverage,death of your spouse, subsection of this section. divorce,legal separation or employer contributions toward such coverage was Special Enrollment Period terminated;and IAn Eligible Employee and/or the Employee's c) you submit the applicable Enrollment Eligible Dependent(s)may apply for coverage Form to the Group within 30 days of the outside of the Initial Enrollment Period and date your coverage was terminated Annual Enrollment Period as a result of a special Note: Loss of coverage for failure to pay enrollment event. To apply for coverage,the your required contribution/premium on a Eligible Employee and/or the Employee's timely basis or for cause(such as making a Eligible Dependent(s)must complete the fraudulent claim or an intentional I applicable Enrollment Form and forward it to Ms misrepresentation of a material fact in Monroe County BOCC Benefits Office within the connection with the prior health coverage)Is time periods noted below for each special not a qualifying event for special enrollment. enrollment event. An Eligible Employee and/or the Employee's or Eligible Dependent(s)may apply for coverage if 2. If when offered coverage under this plan at one of the following special enrollment events the time of initial eligibility,you stated,in occurs and the applicable Enrollment Form Is writing,that coverage under a group health submitted to Monroe County BOCC Benefits plan or health insurance coverage was the Office within the indicated time periods: reason for declining enrollment;and you get Enrollment and Effedve Date al Coverage ,ae married or obtain a dependent through birth, adoption or placement in anticipation of adoption and you submit the applicable Enrollment Form to Monroe County BOCC Benefits Office within 30 days of the date of the event. r 3. If you or your Eligible Dependent(s)lose coverage under a CHIP or Medicaid due to loss of eligibility for such coverage or become eligible for the optional state premium assistance program and you submit the applicable Enrollment Form to Monroe County BOCC Benefits Office within 60 days of the date such coverage was terminated or the date you become eligible for the optional state premium assistance program. The Effective Date of coverage for you and your Eligible Dependents added as a result of a special enrollment event is the date of the special enrollment event. Eligible Employees or Eligible Dependents who do riot enroll or change their coverage selection during the Special Enrollment Period must wait until the next Annual Open Enrollment Period(See the Dependent Enrollment subsection of this section for the rules relating to the enrollment of Eligible Dependents of a Covered Plan Participant). Other Provisions Regarding Enrollment and Effective Date of Coverage I Rehired Employees Individuals who are rehired as employees of Monroe County BOCC or any of the Constitutional Officers or their Employees are considered newly hired employees for purposes of this section. The provisions of the Group Health Plan(which includes this Booklet)which are applicable to newly hired employees and their Eligible Dependents(e.g., enrollment, Effective Dates of coverage,and Waiting Period) are applicable to rehired employees and their Eligible Dependents. Enrolment and Efle Are Date*,Coverage 10-$ Section 11 : Termination of Coverage Termination of a Covered Plan 4. last day of the Calendar Year that the Participant's Coverage Covered Dependent child no longer meets any of the applicable eligibility requirements; A Covered Plan Participant's coverage under this Benefit Booklet win automatically terminate 5. date specified by Monroe County 8OCC that at 12:01 a.m.: the Dependent's coverage is terminated for cause(see the Termination of Individual 1. on the dale the Group Health Plan Coverage for Cause subsection). terminates; In the event you as the Covered Plan Participant 2. on the date the ASO Agreement between wish to delete a Covered Dependent from BCBSF and Monroe County BOCC coverage,an Enrollment Form must be terminates; forwarded to BCBSF through Monroe County 3. on the last day of the first month that the BOCC Benefits Office. Covered Plan Participant fails to continue to In the event you as the Covered Plan Participant meet any of the applicable eligibility wish to terminate a spouse's coverage,(e.g.,in requirements; the case of divorce),you must submit an 4. on the date specified by Monroe County Enrollment Form to Monroe County BOCC,prior BOCC that the Covered Plan Participant's to the requested termination date or within 10 coverage is terminated for cause(see the days of the date the divorce is final,whichever is Termination of an Individual Coverage for applicable. Cause subsection);or Termination of an Individual's 5. on the date specified by Monroe County Coverage for Cause BOCC that the Covered Plan Participant's coverage terminates. In the event any of the following occurs. Monroe Termination of a Covered County BOCC may terminate an Individual's coverage for cause: Dependent's Coverage 1. fraud,material misrepresentation or A Covered Dependent's coverage will omission In applying for coverage or automatically terminate at 12:01 a.m.on the benefits;or date: 2. the knowing misrepresentation,omission or 1. the Group Health Plan terminates; the giving of false information on Enrollment Forms or other forms completed,by or on 2. the Covered Plan Participant's coverage your behalf. terminates for any reason; 3. the Dependent becomes covered under an Notice of Termination alternative health benefits plan which is It is Monroe County BOCC's responsibility to offered through or in connection with the immediately notify you of your termination or that Group Health Plan; of your Covered Dependents for any reason. Tam4rolknW ave:pe II1 to the a"anl C^Vergn-4efm,n^te^fer.^ny r a-en, y u....r^Nf..e....of r•odhnble-Covorago will bo issued-te-yaw TheseriP^alien ef-Gre^Aeblaf a _.en_ ..At indicateenrelled underealth PlanrChedlta l th-etlimeyou Upen-reyeeehanathe.sertifteatien-of Creditable ind' rea ien. The-susseeding-saA espensible-fer Creditable-Coverage guidelines(a:g.,ne-mere brarminne Cownga 114 Section 12: Continuing Coverage Under COBRA A federal continuation of coverage law,known months)if you or your Covered as the Consolidated Omnibus Budget Dependent(s)Is/are totally disabled(as Reconciliation Act of 1985(COBRA),as defined by the Social Security Administration amended,may apply to your Group Health Plan. (SSA))at the time of your termination, If COBRA applies,you or your Covered reduction In hours or within the first 60 days Dependents may be entitled to continue of COBRA continuation coverage. The coverage for a limited period of time,If you meet Covered Person must supply notice of the the applicable requirements,make a timely disability determination to Monroe County election,and pay the proper amount required to BOCC Benefits Office within 18 months of maintain coverage. becoming eligible for continuation coverage You must contact Monroe County 80CC and no later than 60 days after the SSA's Benefits Office to determine if you or your determination date. Covered Dependent(s)are entitled to COBRA 2. Your Covered Dependent(s)may elect to continuation of coverage. Monroe County continue their coverage for a period not to BOCC is solely responsible for meeting all of the exceed 36 months In the case of: obligations under COBRA, including the a) the Covered Plan Participant's obligation to notify all Covered Persons of their rights under COBRA. If you fail to meet your entitlement to Medicare; obligations under COBRA and this Benefit b) divorce or legal separation of the _ Booklet,Monroe County BOCC will not be liable Covered Plan Participant; for any claims incurred by you or your Covered c) death of the Covered Plan Participant; Dependent(s)after termination of coverage. d) the employer files bankruptcy(subject to A summary of your COBRA rights and the bankruptcy court approval);or general conditions for qualification for COBRA continuation coverage is provided below. e) a dependent child may elect the 36 month extension If the dependent child The following is a summary of what you may ceases to be an Eligible Dependent elect,If COBRA applies to Monroe County under the terms of Monroe County BOCC and you are eligible for such coverage: BOCC's coverage. 1. You may elect to continue this coverage for Children born to or placed for adoption with the a period not to exceed 18 months*in the Covered Plan Participant during the continuation ease of: coverage periods noted above are also eligible a) termination of employment of the for the remainder of the continuation period. Covered Plan Participant other than for Additional requirements applicable to gross misconduct;or continuation of coverage under COBRA are set b) reduced hours of employment of the forth below: Covered Plan Participant. 1. Monroe County BOCC must notify you of *Note: You and/or your Covered your continuation of coverage rights under Dependent(s)are eligible for an 11 month COBRA within 14 days of the event which extension of the 18 month COBRA creates the continuation option, If coverage continuation option above(to a total of 29 would be lost due to Medicare entitlement, Continuing Coverage Unix COBRA 12-1 divorce,legal separation or the failure of a An election by a Covered Plan Participant or Covered Dependent child to meet eligibility Covered Dependent spouse shall be deemed to requirements,you or your Covered be an election for any other qualified beneficiary Dependent must notify Monroe County related to that Covered Plan Participant or BOCC Benefits Office,in writing,within 60 Covered Dependent spouse,unless otherwise days of any of these events. Monroe specified in the election form. County BOCC's 14-day notice requirement Note: This section shall not be interpreted to runs from the date of receipt of such notice. grant any continuation rights In excess of 2. You must elect to continue the coverage those required by COBRA and/or Section within 80 days of the later of: 4980E of the Internal Revenue Code. a) the date that the coverage terminates;or Additionally,this Benefit Booklet shall be deemed to have been modified,and shall be b) the date the notification of continuation of Interpreted, so as to comply with COBRA coverage rights is sent by Monroe and changes to COBRA that are mandatory County BOCC. with respect to Monroe County BOCC. 3. COBRA coverage will terminate if you become covered under any other group health insurance plan. However,COBRA coverage may continue if the new group health insurance plan contains exclusions or limitations due to a Pre-existing Condition that would affect your coverage. 4. COBRA coverage will terminate If you become entitled to Medicare. 5. If you are totally disabled and eligible and elect to extend your continuation of coverage,you may not continue such extension of coverage more than 30 days after a determination by the Social Security Administration that you are no longer disabled. You must Inform Monroe County BOCC Benefits Office of the Social Security Administration's determination within 30 days of such determination. 6. You must meet all contribution requirements,and all other eligibility requirements described in COBRA,and,to the extent not Inconsistent with COBRA,in the Group Health Plan. 7. COBRA coverage will terminate on the date Monroe County BOCC ceases to provide group health coverage to its employees. Continuing Coverage Under COBRA 12.2 Section 13: Conversion Privilege Eligibility Criteria for Conversion Additionally,you are not entitled to a converted You are entitled to apply for a BCBSF individual policy If: insurance conversion policy(hereinafter referred 1. you are eligible for or covered under the to as a"converted policy or"conversion policy) Medicare program; If: 2. you failed to pay,on a timely basis,the 1. you were continuously covered for at least contribution required for coverage under the three months under the Group Health Plan, Group Health Plan; and/or under another group policy that provided similar benefits immediately prior to 3. the Group Health Plan was replaced within the Group Health Plan;and 31 days after termination by any group policy,contract,plan,or program,including 2. your coverage was terminated for any a self-Insured plan or program,that provides reason,including discontinuance of the benefits similar to the benefits provided Group Health Plan in its entirety and under this Booklet;or termination of continued coverage under COBRA. 4. a) you fall under one of the following Notify BCBSF in writing or by telephone if you categories and meet the requirements of are interested in a conversion policy. Within 14 4.b.below: days of such notice, BCBSF will send you a i. you are covered under any Hospital, conversion policy application,premium notice surgical,medical or major medical and-outline of coverage. The outline of policy or contract or under a coverage will contain a brief description of the prepayment plan or under any other benefits and coverage,exclusions and plan or program that provides limitations,and the applicable Deductibles)and benefits which are similar to the Coinsurance provisions. benefits provided under this Booklet; BCBSF must receive a completed application or for a converted policy,and the applicable ii. you are eligible,whether or not premium payment,within the 63-day period covered,under any arrangement of beginning on the date the coverage under coverage for individuals in a group, the Group Health Plan terminated. If whether on an insured,uninsured, coverage has been terminated,due to the nonpayment of employee contribution by or partially insured basis,for Monroe County BOCC,BCBSF must receive benefits similar to those provided the completed convened policy application under this Booklet;or and the applicable premium payment within iii. benefits similar to the benefits the 63-day period beginning on the date provided under this Booklet are notice was given that the Group Health Plan provided for or are evadable to you terminated. pursuant to or In accordance with In the event BCBSF does not receive the the requirements of any state or converted policy application and the initial federal law(e.g.,COBRA, premium payment within such 63-day period, Medicaid):and your converted policy application will be denied and you will not be entitled to a converted policy. ComwebnPth ge 131 b) the benefits provided under the sources referred to In paragraph 4.a.i or the benefits provided or available under the source referred to In paragraph 4.a.ii. and 4.a.IiI.above,together with the benefits provided by our converted policy would result in over-insurance in accordance with our over-Insurance standards,as determined by us. Neither Monroe County BOCC nor BCBSF has any obligation to notify you of this conversion privilege when your coverage terminates or at any other time. It is your sole responsibility to exercise this conversion privilege by submitting a BCBSF convened policy application and the initial premium payment to us within 63 days of the termination of your coverage under this Benefit Booklet. The converted policy may be issued without evidence of Insurability and shall be effective the day following the day your coverage under this Benefit Booklet terminated. Note: Our converted policies are not a continuation of coverage under COBRA or any other states'similar laws. Coverage and benefits provided under a converted policy will not be Identical to the coverage and benefits provided under this Booklet. When applying for our converted policy,you have two options: 1)a converted policy providing major medical coverage meeting the requirements of 627.6675(10)Florida Statutes or 2)a converted policy providing coverage and benefits identical to the coverage and benefits required to be provided under a small employer standard health benefit plan pursuant to Section 627.6690(12)Florida Statutes. In any event,we will not be required to issue a converted policy unless required to do so by Florida law. We may have other options available to you. Call the telephone number on your Identification card for more information. Conveeion Privgege i3•2 Section 14: Extension of Benefits Extension of Benefits perform those normal day-to-day activities which you would otherwise perform and you In the event the Group Health Plan Is require regular care and attendance by a terminated,coverage will not be provided under Physician. this Benefit Booklet for any Service rendered on 2 in the event you are receiving covered or after the termination date. The extension of dental treatment as of the termination date benefits provisions described below only apply of the Group Health Plan a limited extension when the entire Group Health Plan Is of such covered dental treatment will be terminated. The extension of benefits described In this section do not apply when your coverage provided under this Benefit Booklet if: terminates If the Group Health Plan remains in a) a course of dental treatment or dental effect, The extension of benefits provisions are procedures were recommended hi subject to all of the other provisions,Including writing and commenced in accordance the limitations and exclusions. with the terms specified herein while you Note: It Is your sole responsibility to provide were covered under the Group Health acceptable documentation showing that you are Plan; entitled to an extension of benefits. b) the dental procedures were procedures for other than routine examinations, 1. In the event you are totally disabled on the termination date of the Group Health Plan as Prophylaxis,x-rays,sealants,Or a result of a specific Accident or Illness orthodontic services;and incurred while you were covered under this c) the dental procedures were performed Booklet,as determined by us,a Umited within 00 days after the Group Health extension of benefits will be provided under Plan terminated. this Benefit Booklet for the disabled This extension of benefits Is for Covered Individual only. This extension of benefits Is Services necessary to complete the for Covered Services necessary to treat the dental treatment only. This extension of disabling Condition only. This extension of benefits will automatically terminate at benefits will only continue as long as the the end of the 90-day period beginning disability is continuous and uninterrupted. In on the termination date of the Group any event,this extension of benefits will Health Plan or on the date you become automatically terminate at the end of the 12- covered under a succeeding insurance, month period beginning on the termination health maintenance self- date of the Group Health Plan. organizationinsuredplan providing coverage or For purposes of this section,you will be Services for similar dental procedures. considered "totally disabled'only if,in our You are not required to be totally or Monroe County BOCC's opinion, you are disabled in order to be eligible for this unable to work at any gainful job for which extension of benefits. you are suited by education,training,or Please refer to the Dental Care category of experience,and you require regular care the'What Is Coveredr secUon for a and attendance by a Physician. You are description of the dental care Services totally disabled only if, in our or Monroe covered under this Booklet. County BOCC's opinion,you are unable to Extension ol genets 141 3. In the event you are pregnant as of the termination date or the Group Health Plan,a limited extension of the maternity expense benefits included in this Booklet will be available,provided the pregnancy commenced while the pregnant IndMdual was covered under the Group Health Plan, as determined by us or Monroe County BOCC. This extension of benefits Is for Covered Services necessary to treat the pregnancy only. This extension of benefits will automatically terminate on the date of the birth of the child. You are not required to be Totally Disabled in order to be eligible for this extension of benefits. Eaealcn of aereae 14-2 Section 15: The Effect of Medicare Coverage/Medicare Secondary Payer Provisions When you become covered under Medicare and disability whose employer has less than 100 continue to be eligible and covered under this employees,retirees and/or their spouses over Benefit Booklet,coverage under this Benoit the age of 65). Also,if coverage under this Booklet will be primary and the Medicare Benefit Booklet was primary prior to ESRD benefits will be secondary, but only to the extent entitlement,then coverage hereunder will required by law. In all other instances,coverage remain primary for the ESRD coordination under this Benefit Booklet will be secondary to period. If you become eligible for Medicare due any Medicare benefits. To the extent the to ESRD,coverage will be provided,as benefits under this Benefit Booklet are primary, described in this section,on a primary basis for claims for Covered Services should be filed with 30 months. BCBSF first. Disabled Active Individuals Under Medicare,Monroe County BOCC MAY NOT offer,subsidize,procure or provide a If you are entitled to Medicare coverage Medicare supplement policy to you. Also, because of a disability other than ESRD, Monroe County BOCC MAY NOT Induce you to Medicare benefits will be secondary to the decline or terminate your group health insurance benefits provided under this Benefit Booklet coverage and elect Medicare as primary payer. provided that If you become 65 or become eligible for Monroe County BOCC employed at least 100 or Medicare due to End Stage Renal Disease mare full-time or part-time employees on 50%or ('ESRD'), you must immediately notify Monroe more of its regular business days during the County BOCC Benefits Office. previous Calendar Year. If the Group Health Plan is a multi-employer plan,as defined by Individuals With End Stage Renal Medicare,Medicare benefits will be secondary if Disease at least one employer participating in the plan If you are entitled to Medicare coverage covered 100 or more employees under the plan because of ESRD,coverage under this Benefit on 50%or more of Its regular business days Booklet will be provided on a primary basis for during the previous Calendar Year. 30 months beginning with the earlier of: Miscellaneous 1. the month In which you became entitled to Medicare Part'A"ESRD benefits; or 1. This section shall be subject to,modified(If necessary)to conform to or comply with, 2. the first month in which you would have and Interpreted with reference to the been entitled to Medicare Pan'A"ESRD benefits if a timely application had been requirements of federal statutory and made. regulatory Medicare Secondary Payer provisions as those provisions relate to if Medicare was primary prior to the time you Medicare beneficiaries who are covered became eligible due to ESRD,then Medicare under this Benefit Booklet. will remain primary(I.e.,persons entitled due to The Effect of Medicate Coverage/Medicare Secondary Pays:Provisions 15.1 2. BCSSF will not be liable to Monroe County BOCC or to any Individual covered under this Benefit Booklet on account of any nonpayment of primary benefits resulting from any failure of performance of Monroe County BOCC's obligations as described in this section. The Ellect or Meecare Coverage'Medicare Secondary Payer Rovhione 15.2 Section 16: Duplication of Coverage Under Other Health • Plans/Programs Coordination of Benefits with which the law permits coordination of benefits; Coordination of Benefits('COB")is a limitation 4. Medicare,as described in"The Effect of of coverage and/or benefits to be provided under Medicare Coverage/Medicare Secondary this Benefit Booklet. Payer Provisions'section; and COB determines the manner in which expenses will be paid when you are covered under more 5. to the extent permitted bylaw,any other than one health plan,program,or policy government sponsored health insurance providing benefits for Health Care Services. Program. I COB is designed to avoid the costly duplication The amount of payment,If any,when benefits of payment for Covered Services. It Is your are coordinated under this section,Is based on responsibility to provide BCBSF and Monroe whether or not the benefits under this Benefit County BOCC Benefits Office information Booklet are primary. When primary,payment concerning any duplication of coverage under will be made for Covered Services without any other health plan, program,or policy you or regard to coverage under other plans. When the your Covered Dependents may have. This benefits under this Benefit Booklet are not means you must notify BCBSF and Monroe primary,payment for Covered Services may be County BOCC Benefits Office in wilting if you reduced so that total benefits under all your have other applicable coverage or if there Is no plans will not exceed 100 percent of the total other coverage. You may be requested to reasonable expenses actually incurred for provide this information at initial enrollment,by Covered Services. For purposes of this section, written correspondence annually thereafter,or in in the event you receive Covered Services from connection with a specific Health Care Service an In-Network Provider or an Out-of-Network you receive. If the information is not received. Provider who participates in the Traditional claims may be denied and you will be Program,"total reasonable expenses"shall responsible for payment of any expenses related mean the total amount required to be paid to the to denied claims. Provider pursuant to the applicable agreement Health plans,programs or policies which may be BCBSF or another Blue Cross and/or Blue subject to COB include, but are not limited to, Shield organization has with such Provider. In the following which will be referred to as the event that the primary payers payment "plan(s)"for purposes of this section: exceeds the Mowed Amount, no payment will be made for such Services. 1. any group or non-group health insurance, The following rules shall be used to establish the group-type self-Insurance,or HMO plan; order in which benefits under the respective 12. any group plan issued by any Blue Cross plans will be determined: and/or Blue Shield organization(s); 1. When you are covered as a Covered 3. any other plan,program or insurance policy, Dependent and the other plan covers you as including an automobile PIP Insurance other than a dependent,the Group Health policy and/or medical payment coverage Plan will be secondary. Dupinalbn or Coverage Under CNN Heat PlenrlRogrmm ,b! 2. When the Group Health Plan covers a excess insurance policy, a policy with dependent child whose parents are not coverage limited to specified illnesses or separated or divorced: accidents,or a Medicare supplement policy. a) the plan of the parent whose birthday, 8. If you are covered under a COBRA excluding year of birth, falls earlier In the continuation plan as a result of the purchase year will be primary;or of coverage as provided under the Consolidated Omnibus Budget b) if both parents have the same birthday, Reconciliation Act of 1885,as amended, excluding year of bkth,and the other and also under another group plan,the plan has covered one of the parents following order of benefits applies: longer than us,the Group Health Plan will be secondary. a) first,the plan covering the person as an employee,or as the employee's 3. When the Group Health Plan covers a Dependent;and dependent child whose parents are separated or divorced: b) second,the coverage purchased under the plan covering the person as a former a) if the parent with custody is not employee,or as the former employee's remarried,the plan of the parent with Dependent provided according to the custody is primary; provisions of COBRA. b) If the parent with custody has remarried, 7. If the other plan does not have rules that the plan of the parent with custody Is establish the same order of benefits as primary;the stepparent's plan Is under this Booklet,the benefits under the secondary;and the plan of the parent other plan will be determined primary to the without custody pays last; benefits under this Booklet. 1 c) regardless of which parent has custody, whenever a court decree specifies the Coordination of benefits shall not be permitted parent who is financially responsible for against an indemnity-type policy,an excess the child's health care expenses,the insurance policy as defined in Florida Statutes plan of that parent Is primary. Section 827.835,a policy with coverage limited to specified illnesses or accidents,or a Medicare I 4. When the Group Health Plan covers a supplement policy. dependent child and the dependent child is also covered under another plan: Non-Duplication of Government a) the plan of the parent who is neither laid Programs and Worker's off nor retired will be primary;or Compensation b) If the other plan is not subject to this The benefits under this Booklet shall not rule,and if,as a result,such plan does duplicate any benefits to which you or your not agree on the order of benefits,this Covered Dependents are entitled to or eligible paragraph shall not apply. for under government programs(e.g., Medicare, I 5. When rules 1, 2, 3,and 4 above do not Medicaid, Veterans Administration)or Workers establish an order of benefits, the plan which Compensation to the extent allowed by law,or has covered you the longest shall be under any extension of benefits of coverage primary. under a prior plan or program which may be provided or required by law. The Group Health Plan will not coordinate benefits against an indemnity-type policy,an Oagloagm of Coverage Under Other Heald Pan&Frogreme 16.2 Section 17: Subrogation In the event payment is made under this Benefit legal representative shall promptly notify BCBSF Booklet to you or on your behalf far any claim in In writing of any settlement negotiations prior to connection with or arising from a Condition entering Into any settlement agreement,shall resuking,directly or indrectiy,from an disclose to BCBSF any amount recovered from Intentional act or from the negligence or fault of any person or entity that may be liable,and shall any third person or entity, Monroe County BOCC not make any distributions of settlement or and/or the Group Health Plan,to the extent of judgement proceeds without Monroe County any such payment,shall be subrogated to all BOCC's prior written consent. No waiver, causes of action and all rights of recovery you release of liability,or other documents executed have against any person or entity. Such by you without such notice to BCBSF shall be subrogation rights shall extend and apply to any binding upon Monroe County BOCC. settlement of a claim,regardless of whether litigation has been initiated. BCBSF may recover,on behalf of Monroe County BOCC and/or the Group Health Plan,the amount of any payments made on your behalf minus BCBSF or Monroe County BOCC's pro rata share for any costs and attorney fees Incurred by you in pursuing and recovering damages. BCBSF may subrogate,on behalf of Monroe County BOCC and/or the Group Health Plan,against all money recovered regardless of the source of the money including,but not limited to,uninsured motorist coverage. Although Monroe County BOCC may,but is not required to,lake into consideration any special factors relating your specific case in resolving the subrogation claim, Monroe County BOCC will have the first right of recovery out of any recovery or settlement amount you are able to obtain even If you or your attorney believes that you have not been made whole for your losses or damages by the amount of the recovery or setUemenl. You must promptly execute and deliver such instruments and papers pertaining to such settlement of claims,settlement negotiations,or litigation as may be requested by BCBSF or Monroe County BOCC,and shall do whatever Is necessary to enable BCBSF or Monroe County BOCC to exercise Monroe County BOCC's subrogation rights and shall do nothing to prejudice such rights. Additionally, you or your $Wrogabn Ir.l Section 18: Right of Reimbursement If any payment under this Benefit Booklet is made to you or on your behalf with respect to any injury or illness resulting from the intentional act, negligence,or fault of a third person or entity,Monroe County BOCC and/or the Group Health Plan will have a right to be reimbursed by you(out of any settlement or judgment proceeds you recover)one dollar($1.00)for each dollar paid under the terms of the Group Health Plan minus a pro rata share for any casts and attorney fees incurred in pursuing and recovering such proceeds. Monroe County BOCC's and/or the Group Health Plan's right of reimbursement will be In addition to any subrogation right or claim available to Monroe County BOCC,and you must execute and deliver such instruments or papers pertaining to any settlement or claim, settlement negotiations,or litigation as may be requested by BCBSF on behalf of Monroe County BOCC,and/or the Group Health Plan,to exercise Monroe County BOCC's and/or the Group Health Plan's right of reimbursement hereunder. You or your lawyer must notify us, by certified or registered mail, If you intend to claim damages from someone for Injuries or Illness. You must do nothing to prejudice Monroe County BOCC's and/or the Group Health Plan's right of reimbursement hereunder and no waiver,release of liability, or other documents executed by you,without notice to us and our written consent,acting on behalf of Monroe County BOCC,will be binding upon Monroe County BOCC. RlgN daeSbnow,er4 10.v Section 19: Claims Processing Introduction Post-Service Claims This section Is Intended to: How to File a Post-Service Claim • help you understand what you or your We have defined and described the three types treating Providers must do,under the terms of claims that may be submitted to us. Our of this Benefit Booklet,in order to obtain experience shows that the most common type of payment for expenses for Covered Services claim we will receive from you or your treating they have rendered or will render to you; Providers will likely be Post-Service Claims. and In-Network Providers have agreed to file Post- • provide you with a general description of the Service Claims for Services they render to you. applicable procedures we wiW use for In the event a Provider who renders Services to making Adverse Benefit Determinations, you does not file a Post-Service Claim for such Concurrent Care Decisions and for notifying Services,it is your responsibility to file It with us. you when we deny benefits. We must receive a Post-Service Claim within 90 Under no circumstances will we be held days of the date the Health Care Service was responsible for, nor will we accept liability rendered or,if it was not reasonably possible to relating to,the(allure of your Group Plan's file within such 90-day period, as soon as sponsor or plan administrator to: 1)comply with Possible. In any event,no Post-Service Claim any applicable disclosure requirements; will be considered for payment if we do not 2)provide you with a Summary Plan Description receive it at the address Indicated on your ID (SPD);or 3)comply with any other legal Card within one year of the date the Service was requirements. You should contact your plan rendered unless you were legally incapacitated. sponsor or administrator if you have questions For Post-Service Claims,we must receive an relating to your Group Plan's SPD. We are not itemized statement from the health care Provider your Group Plan's sponsor or plan administrator. for the Service rendered along with a completed In most cases,a plan's sponsor or plan claim form. The itemized statement must administrator is the employer who establishes contain the following information: and maintains the plan. 1. the date the Service was provided; Types of Claims 2. a description of the Service including any applicable procedure code(s); For purposes of this Benefit Booklet,there are three types of claims: 1)Pre-Service Claims; 3. the amount actually charged by the 2)Post-Service Claims;and 3)Claims Involving Provider; Urgent Care. It is important that you become 4. the diagnosis including any applicable familiar with the types of claims that can be diagnosis code(s); submitted to us and the timeframes and other 6. the Provider's name and address; requirements that apply. 6. the name of the individual who received the Service;and Claims Processing 19.11 7. the Covered Plan Participants name and claim or a portion of the claim Is contested. Our contract number as they appear on the ID notice may identify:1)the contested portion or Card. portions of the claim;2)the reason(s)for The itemized statement and claim form must be contesting the claim or a portion of the claim; received by us at the address Indicated on your and 3)the date that we reasonably expect to ID Card. notify you of the decision. The notice may also indicate whether additional information is Note:-Special claims processing rules may needed in order to complete processing of the apply for Health Care Services you receive claim. If we request additional information,we outside the state of Florida under the BlueCard must receive it within 45 days of our request for Program(See the°BlueCard(Out-of-State) the Information. If we do not receive the Program'section of this Booklet). requested information,the claim or a portion The Processing of Post-Service Claims of the claim will be adjudicated based on the information in our possession at the time We will use our best efforts to pay,contest,or and may be denied. Upon receipt of the deny all Post-Service Claims for which we have requested information,we will use our best all of the necessary information,as determined efforts to complete the processing of the Post- by us. Post-Service Claims will be paid, Service Claim within 15 days of receipt of the contested,or dented within the timeframes information. described below. • Denial of Post-Service Claims • Payment for Post-Service Claims in the event we deny a Post-Service Claim When payment is due under the terms of this submitted electronically,we will use our best Benefit Booklet,we will use our best efforts to efforts to provide notice,within 20 days of pay(in whole or in part)for electronically receipt,that the claim or a portion of the claim S submitted Post-Service Claims within 20 days of denied. In the event we deny a paper Post- receipt. Likewise,we will use our best efforts to Service Claim,we will use our best efforts to pay(in whole or in part)for paper Post-Service provide notice,within 30 days of receipt,that the Claims within 40 days of receipt. You may claim or a portion of the claim is denied. The receive notice of payment for paper claims notice may identify the denied portlon(s)of the within 30 days of receipt. If we are unable to claim and the reason(s)for denial. It Is your determine whether the claim or a portion of the responsibility to ensure that we receive all claim is payable because we need more or information determined by us as necessary to additional information, we may contest the claim adjudicate a Post-Service Claim. If we do not within the timeframes set forth below. receive the necessary information,the claim or a portion of the claim may be denied. • Contested Post-Service Claims A Post-Service Claim denial is an Adverse In the event we contest an electronically Benefit Determination and is subject to the submitted Post-Service Claim,or a portion of Adverse Benefit Determination standards and such a claim,we will use our best efforts to appeal procedures described in this section. provide notice,within 20 days of receipt,that the claim or a portion of the claim Is contested. In Additional Processino information for Post- the event we contest a Post-Service Claim •5ervica Claims submitted on a paper claim form,or a portion of In any event,we will use our best efforts to pay such a claim,we will use our best efforts to or deny all: 1)electronic Post-Service Claims provide notice,within 30 days of receipt,that the within 90 days of receipt of the completed claim; Ceimf Prvcessi g 194 and 2)Post-Service paper claims within 120 )3enefit Determinations on Pre-Service Claims days of receipt of the completed claim. Claims Involving Urgent Cnre processing shad be deemed to have been For a Pre-Service Claim Involving Urgent Care, completed as of the date the notice of the claims we will use our best efforts to provide notice of decision Is deposited in the mall by us or our determination(whether adverse or not)as otherwise electronically transmitted. Any claims soon as possible,but not later than 72 hours payment relating to a Post-Service Claim that is after receipt of the Pre-Service Claim unless not made by us within the applicable tkneframe additional Information is required for a coverage is subject to the payment of simple interest at decision. If additional Information is necessary the rate established by the Florida Insurance to make a determination,we will use our best Code. efforts to provide notice within 24 hours of: 1) We will investigate any allegation of improper the need for additional information;2)the billing by a Provider upon receipt of written specific information that you or your Provider notification from you. If we determine that you may need to provide; and 3)the date that we were billed for a Service that was not actually reasonably expect to provide notice of the performed,any payment amount will be adjusted decision. If we request additional information, and, If applicable,a refund will be requested. In we must receive it within 48 hours of our such a case,if payment to the Provider is requesL We will use our best efforts to provide reduced due solely to the notification from you, notice of the decision on your Pre-Service Claim we will pay you 20 percent of the amount of the within 48 hours after the earlier of: 1)receipt of reduction,up to a total of$500. the requested Information;or 2)the end of the period you were afforded to provide the Pro-Service Claims specified additional information as described above. How to File a Pre-Service Claim Benefit Determinations on Pre-Service Claims This Benefit Booklet may condition coverage, that Do Not Involve Uroent Care benefits,or payment(in whole or in part), for a specific Covered Service,on the receipt by us of We will use our best efforts to provide notice of a a Pre-Service Claim as that temp is defined decision on a Pre-Service Claim not Involving herein. In order to determine whether we must urgent care within 15 days of receipt provided receive a Pre-Service Claim for a particular additional information Is not required for a Covered Service,please refer to the'What Is coverage decision. This 15-day determination Covered?"section and other applicable sections period may be extended by us one time for up to of this Benefit Booklet. You may also call the an additional 15 days. If such an extension Is customer service number on your ID card for necessary,we will use our best efforts to provide assistance. notice of the extension and reasons for it. We will use our best efforts to provide notification of We are not required to render an opinion or the decision on your Pre-Service claim within a make a coverage or benefit determination with total of 30 days of the initial receipt of the claim, respect to a Service that has not actually been if an extension of time was taken by us. provided to you unless the terms of this Benefit Booklet require(or condition payment upon) If additional information Is necessary to make a approval by us for the Service before it Is delemrination,we will use our best efforts to: received. 1)provide notice of the need for additional information,prior to the expiration of the initial 15-day period;2)identify the specific Information Gains Preceseag tog that you or your Provider may need to provide; your appeal before we actually terminate or and 3)inform you of the date that we reasonably reduce coverage for the Services. expect to notify you of our decision. If we Requests for Extension of Service% request additional information,we must receive it within 45 days of our request for the Your Provider may request an extension of Information. We will use our best efforts to coverage or benefits for a Service beyond the provide notification of the decision on your Pre- approved period of time or number of approved Service Claim within 16 days of receipt of the Services.If the request for an extension is for a requested Information. Claim Involving Urgent Care,we will use our A Pre-Service Claim denial Is an Adverse best efforts to notify you of the approval or dental Benefit Determination and is subject to the of such requested extension within 24 hours Adverse Benefit Determination standards end after receipt of your request,provided it is appeal procedures described in this section. received at least 24 hours prior to the expiration of the previously approved number or length of Concurrent Care Decisions coverage for such Services. We will use our best efforts to notify you within 24 hours if: 1)we Reduction or Termination of Coverage or need additional information;or 2)you or your perverts for Services representative failed to follow proper procedures A reduction or termination of coverage or in your request for an extension.If we request benefits for Services will be considered an additional information,you will have 48 hours to Adverse Benefit Determination when: provide the requested information.We may notify you orally or in writing,unless you or your • we have approved In writing coverage or representative specifically request that it be in benefits for an ongoing course of Services to writing. A denial of a request for extension of be provided over a period of time or a Services is considered an Adverse Benefit number of Services to be rendered;and Determination and is subject to the Adverse • the reduction or termination occurs before Benefit Determination review procedure below. the end of such previously approved time or number of services:and Standards for Adverse Benefit Determinations • the reduction or termination of coverage or benefits by us was not due to an Manner and Content of a Notification of an amendment of this Benefit Booklet or Adverse Benefit Determination: termination of your coverage as provided by We will use our best efforts to provide notice of this Benefit Booklet. any Adverse Benefit Determination in writing. We will use our best efforts to notify you of such Notification of an Adverse Benefit Determination reduction or termination In advance so that you will include(or will be made available to you free will have a reasonable amount of time to have of charge upon request): the reduction or termination reviewed in 1. the date the Service or supply was provided: accordance with the Adverse Benefit Determination standards and procedures 2. the Provider's name; described below. In no event shall we be 3. the dollar amount of the claim,if applicable; required to provide more than a reasonable period of time within which you may develop 4. the diagnosis codes Included on the claim (e.g.,ICD•9, DSM-IV),including a description of such codes; Claims flocessim 19.4 5. the standardized procedure code Included How to Appeal an Adverse Benefit on the claim(e.g.,Current Procedural Determination Terminology), including a description of such codes; Except as described below,only you,or a 5. the specific reason or reasons for the representative designated by you in writing, Adverse Benefit Determination,including have the right to appeal an Adverse Benefit any applicable denial code; Determination. An appeal of an Adverse Benefit Determination will be reviewed using the review 7. a description of the specific Benefit Booklet process described below. Your appeal must be provisions upon which the Adverse Benefit submitted to us in writing for an internal appeal Determination is based, es well as any within 365 days of the original Adverse Benefit internal rule,guideline,protocol,or other Determination,except in the case of Concurrent similar criterion that was relied upon in Care Decisions which may,depending upon the making the Adverse Benefit Determination; circumstances,require you to file within a B. a description of any additional Informationshorter period of time from notice of the denial. that might change the determination and ofd The following guidelines are applicable to why that information Is necessary; reviews Adverse Benefit DelerminaUons: 9. a description of the Adverse Benefit • We must receive your appeal of an Adverse Benefit Determination in person or in writing; Determination review procedures and the time limits applicable to such procedures; • You may request to review pertinent documents,such as any internal rule, 10. if the Adverse Benefit Determination is guideline,protocol,or similar criterion relied based on the Medical Necessity or upon to make the determination,and submit Experimental or Investigational limitations issues or comments in writing: and exclusions,a statement telling you how • if the Adverse Benefit Determination is to obtain the specific explanation of the based on the lack of Medical Necessity of a scientific or clinical judgment for the particular Service or the Experimental or determination;and Investigational exclusion,you may request, 11. You have the right to an independent free of charge,an explanation of the external review through an external review any,f r t or clinical Judgment relied upon,if organization for certain appeals,as provided any,for the determination,that applies the in the Patient Protection and Affordable terms of this Benefit Booklet to your medical Care Act of 2010. circumstances; • During the review process,the Services in If the claim is a Claim Involving Urgent Care,we question will be reviewed without regard to may notify you orally within the proper the decision reached in the initial timeframes,provided we follow-up with a written determination; or electronic notification meeting the • We may consult with appropriate requirements of this subsection no later than three days after the oral notification. Physicians,as necessary; • Any Independent medical consultant who reviews your Adverse Benefit Determination on our behalf will be identified upon request; Claims]ryces*Ig t9-5 • If your claim is a Claim Involving Urgent the lime of the benefit determination on review, Care,you may request an expedited appeal not as of the time the Service was initially orally or in writing In which case all reviewed or provided. necessary Information on review may be transmitted between you and us by You,or a Provider acting on your behalf,who telephone,facsimile or other available has had a claim denied as not Medically expeditious method;and Necessary has the opportunity to appeal the claim denial.The appeal may be directed to an • If you wish to give someone else permission employee of BCBSF who is a licensed Physician to appeal an Adverse Benefit Determination responsible for Medical Necessity reviews.The on your behalf,we must receive a appeal may be by telephone and the Physician completed Appointment of Representative will respond to you,within a reasonable time,not the person who will represent you with to exceed 15 business days. Requests for an respect to the appeal. An Appointment of internal appeal should be sent to the address Representative form is not required if your below: Physician Is appealing an Adverse Benefit Blue Cross and Blue Shield of Florida,Inc. Determination relating to a Claim Involving Attention: Member Appeals Urgent Care. Appointment of P.O.Box 44197 Representative forms are available at Jacksonville, Florida 32231-4197 www.fioridablue.com or by calling the number on the back of your BCBSF ID Card. How to Request External Review of Timing of Our ADPeai Review on Adverse Our Appeal Decision Benefit Determinations If we deny your appeal and our decision involves We will use our best efforts to review your a medical Judgment,including,but not limited to, appeal of an Adverse Benefit Determination and a decision based on Medical Necessity, communicate the decision In accordance with appropriateness,health care selling,level of the following time frames: care or effectiveness of the Health Care Service or treatment you requested or a determination • Pre-Service Claims—within 30 days of the that the treatment is Experimental or receipt of your appeal;or Investigational,you are entitled to request an • Post-Service Claims—within 60 days of the independent,external review of our decision. receipt of your appeal;or Your request will be reviewed by an independent third party with clinical and legal expertise • Claims Involving Urgent Care(and requests ("External Reviewer)who has no association to extend concurrent care Services made with us. If you have any questions or concerns within 24 hours prior to the termination of the during the external review process,please Services)—within 72 hours of receipt of your contact us at the phone number listed on your ID request.If additional Information is card or visit www.floridablue.cont. You may nacessag we will notify you within 24 hours submit additional written comments to External and we must receive the requested Reviewer. A letter with the mailing address will additional information within 48 hours of our be sent to you when you file an external review. request.After we receive the additional Please note that If you provide any additional information,we will have an additional 48 information during the external review process it hours to make a final determination. will be shared with us in order to give us the opportunity to reconsider the denial. Submit Note:The nature of a claim for Services(i.e. your request in writing on the External Review whether it is'urgent care'or not)is Judged as of Claims Pmcestixe 1943 Request form within four months after receipt of You are entitled to receive,upon written request your denial to the below address: and free of charge,reasonable access to,and Blue Cross and Blue Shield of Florida copies of all documents relevant to your appeal Attention: Member External Reviews DCC9-5 including a copy of the actual benefit provision, Post Office Box 44197 guideline protocol or other similar criterion on Jacksonville, FL 32231.4197 which the appeal decision was based. I if you have a medical Condition where the You may request and we will provide the timeirame for completion of a standard external diagnosis and treatment codes,as well as their review would seriously Jeopardize your life, corresponding meanings,applicable to this health or ability to regain maximum function,you notice,if available. may file a request for art expedited external review. Generally,an urgent situation is one in Additional Claims Processing which your health may be in serious jeopardy, or Provisions in the opinion of your Physician,you may 1. Release of Information/Cooperation: experience pain that cannot be adequately controlled while you wait for a decision on the In order to process claims,we may need external review of your claim. Moreover certain information,including information expedited external reviews may be requested for regarding other health care coverage you an admission,availability of care,continued stay may have. You must cooperate with us in or Health Care Service for which you received our effort to obtain such Information by, Emergency Services,but have not been among other ways,signing any release of discharged from a facility. Please be sure your information form at our request. Failure by treating Physician completes the appropriate you to fully cooperate with us may result in a form to Initiate this request type. If you have any denial of the pending claim and we will have questions or concerns during the external review no liability for such claim. process,please contact us at the phone number listed on your ID card or visit 2. Physical Examination: www.0oridablue.com. You may submit In order to make coverage and benefit additional written comments to the External decisions,we may,at our expense,require Reviewer. A letter with the mailing address will be sent to you when you file an external review. Provideroo o be examined b a health care Please note that ifreasonably or our choicesa a often as is you provide any additional reasonably necessary while a claim Is information during the external review process it will be shared with us in order to give us the pending. Failure by you to fully cooperate with such examination shall result in a denial opportunity to reconsider the denial. If you believe your situation is urgent,you may request of the pending claim and we shall have no an expedited review by sending your request to liability for such claim. the address above or by fax to 904-565-6637. 3. Legal Actions: If the-External Reviewer decides to overturn our No legal action arising out of or In decision,we will provide coverage or payment connection with coverage under this Benefit for your health care item or Service. Booklet may be brought against us within You or someone you name to act for you may the 60•day period following our receipt of the file a request for external review. To appoint completed claim as required herein. someone to act on your behalf,please complete Additionally,no such action may be brought an Appointment of Representative form. after expiration of the applicable statute of limitations. Claims Processing iAl 4. Fraud,Misrepresentation or Omission in specific explanation of the scientific or Applying for Benefits: clinical judgment for the determination. We rely on the information provided on the 6. Circumstances Beyond Our Control: Itemized statement and the claim form when processing a claim. All such information, To the extent that natural disaster,war,riot, therefore,must be accurate,truthful and civil insurrection,epidemic,or other complete. Any fraudulent statement, emergency or similar event not within our omission or concealment of facts, control,results in facilities,personnel or our misrepresentation,or incorrect information financial resources being unable to process may result,in addition to any other legal claims for Covered Services,we will have no remedy we may have,in denial of the claim liability or obligation for any delay in the or cancellation or rescission of your payment of claims for Covered Services, coverage. except that we will make a good faith effort 5. Explanation of Benefits Form: to make payment for such Services,taking into account the impact of the event. For the All claims decisions,including denial and purposes of this paragraph,an event is not claims review decisions,will be within our control if we cannot effectively communicated to you in writing either on an exercise influence or dominion over its explanation of benefits form or some other occurrence or non-occurrence. written correspondence.This form may Indicate: a) The specific reason or reasons for the Adverse Benefit Determination; b) Reference to the specific Benefit Booklet provisions upon which the Adverse Benefit Determination is based as well as any Internal rule,guideline, protocol,a 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 you how you can obtain the Claims Processing 19-8 Section 20: Relationship Between the Parties BCBSF/Monroe County BOCC and nor Monroe County BOCC will be liable,whether Health Care Providers in tort or contract or otherwise,for any acts or omissions of any other person or organization Neither BCBSF nor Monroe County BOCC nor with which BCBSF has made or hereafter makes any of their officers,directors or employees arrangements for the provision of Covered provides Health Care Services to you. Rather, Services. BCBSF is not your agent,servant,or BCBSF and Monroe County BOCC are engaged representative nor is BCBSF an agent,servant, In making coverage and benefit decisions under or representative of Monroe County BOCC and this Booklet. By accepting the Group health BCBSF will not be liable for any acts or care coverage and benefits,you agree that omissions,or those of Monroe County BOCC,its making such coverage and benefit decisions agents,servants,employees,or any person or does not constitute the rendering of Health Care organization with which Monroe County BOCC Services and that health care Providers has entered into any agreement or arrangement. rendering those Services are not employees or By acceptance of coverage and benefits agents of BCBSF or Monroe County BOCC. In hereunder,you agree to the foregoing. this regard,we and Monroe County BOCC hereby expressly disclaim any agency Medical Treatment Decisions - relationship,actual or Implied,with any Responsibility of Your Physician, Not health care Provider. BCBSF and Monroe BCBSF County BOCC do not,by virtue of making coverage,benefit,and payment decisions, Any and all decisions that require or pertain to exercise any control or direction over the independent professional medical judgment or medical judgment or clinical decisions of any training,or the need for medical Services or health care Provider. Any decisions made under supplies,must be made solely by your family the Group Health Plan concerning and your treating Physician in accordance with appropriateness of setting, or whether any the patient/physician relationship. It Is possible Service is Medically Necessary,shall be that you or your treating Physician may conclude deemed to be made solely for purposes of that a particular procedure is needed, determining whether such Services are covered, appropriate,or desirable,even though such and not for purposes of recommending any procedure may not be covered. treatment or non-treatment. Neither BCBSF nor Monroe County BOCC will assume liability for any loss or damage arising as a result of acts or omissions of any health care Provider. Non Liability of BCBSF and Monroe County BOCC Neither Monroe County BOCC nor any person covered under this Booklet is BCBSF's agent or representative,and neither shall be liable for any acts or omissions by BCBSF's agents,servants, employees,or us. Additionally,neither BCBSF aeatbmMp aeMeen the Parties 2t 1 Section 21 : General Provisions Access to Information Compliance with State and Federal Laws and Regulations BCBSF and Monroe County BOCC have the right to receive,from you and any health care The terms of coverage and benefits to be Provider rendering Services to you,information provided under this Benefit Booklet shall be that Is reasonably necessary,as determined by deemed to have been modified and shall be BCBSF and Monroe County BOCC,in order to Interpreted,so as to comply with applicable state administer the coverage and benefits provided, or federal laws and regulations dealing with subject to all applicable confidentiality benefits,eligibility,enrollment,termination,or requirements listed below. By accepting other rights and duties. coverage,you authorize every health care Provider who renders Services to you,to Confidentiality disclose to BCBSF and Monroe County BOCC or to affiliated entitles,upon request,as facts, Except as otherwise specifically provided herein, records,and reports pertaining to your care, and except as may be required in order for us to treatment,and physical or mental Condition,and administer coverage and benefits,specific to permit BCBSF and/or Monroe County BOCC medical Information concerning you,received by to copy any such records and reports so Providers,shall be kept confidential by us in obtained. conformity with applicable law. Such information may be disclosed to third parties for use In Right to Receive Necessary connection with bona fide medical research and Information education,or as reasonably necessary in connection with the administration of coverage in order to administer coverage and benefits, and benefits,specifically including BCBSF's BCBSF or Monroe County BOCC may.without quality assurance and Blueprint for Health the consent of,or notice to,any person,plan,or Programs. Additionally,we may disclose such organization,obtain from any person,plan,or information to entitles affiliated with us or other organization any information with respect to any persons or entities we utilize to assist In providing coverage, benefits or services under person covered under this Booklet or applicant this Booklet. Further,any documents or for enrollment which BCBSF or Monroe County BOCC deem to be necessary. information which ere properly subpoenaed in a judicial proceeding,or by order of a regulatory Right to Recovery agency,shall not be subject to this provision. BCBSF's arrangements with a Provider may Whenever the Group Health Plan has made require that we release certain claims end payments in excess of the maximum provided medical information about persons covered for under this Booklet, BCBSF or Monroe under this Booklet to that Provider even if County BOCC will have the right to recover any treatment has not been sought by or through such payments,to the extent of such excess, that Provider. By accepting coverage, you from you or any person, plan,or other hereby authorize us to release to Providers organization that received such payments. claims information,Including related medical Information,pertaining to you in order for any such Provider to evaluate your financial responsibility under this Booklet. General Provisions 21.1 Benefit Booklet constitute a waiver of any such terms or conditions. Further,it will not affect BCBSFs or You have been provided with this Benefit Monroe County BOCC's right at any time to Booklet and an Identification Card as evidence enforce any terms or conditions under this of your coverage under this Benefit Booklet. Benefit Booklet. Modification of Provider Network and Notices the Participation Status My notice required or permitted hereunder will NetwodcBlue and the Traditional Provider be deemed given if hand delivered or if mailed Program,and the participation status of by United States Mail,postage prepaid,and Individual Providers available through BCBSF, addressed as listed below. Such notice will be are subject to change at any time by BCBSF deemed effective as of the date delivered or so without prior notice to you or your approval or deposited in the mall. that of Monroe County BOCC. Additionally, If to BCBSF: BCBSF may,at any time,terminate or modify the terms of any Provider contract and may To the address printed on the Identification enter into additional Provider contracts without Card. prior nonce to you, or your approval or that of If to you: Monroe County BOCC. It is your responsibility to determine whether a health care Provider is To the latest address provided by you or to an In-Network Provider at the time the Health your latest address on Enrollment Forms Care Service is rendered. Under this Booklet, actually delivered to us. your_financial responsibility may vary depending You must notify Monroe County BOCC upon a Providers participation status. Benefits Office immediately of any address change. Cooperation Required of You and Your Covered Dependents It to Monroe County BOCC: To the address indicated by Monroe County You must cooperate with BCBSF and Monroe BOCC. County BOCC, and must execute and submit to us any consents,releases,assignments,and Our Obligations Upon Termination other documents requested In order to administer,and exercise any rights hereunder. Upon termination of your coverage for any Failure to do so may result in the denial of reason,there will be no further liability or claims and will constitute grounds for termination responsibility to you under the Group Health for cause(See the Termination of an Individual's Plan,except as specifically described herein. Coverage for Cause subsection in the Termination Of Coverage section). Promissory Estoppel Non-Waiver of Defaults No oral statements,representations,or understanding by any person can change,alter, Any failure by BCBSF or Monroe County BOCC delete,add,or otherwise modify the express at any time,or from time to time,to enforce or to written terms of this Booklet. require the strict adherence to any of the terms or conditions described herein,will in no event General Provisions 21.2 Florida Agency for Health Care Administration Performance Data The performance outcome and financial data published by the Agency for Health Care Administration(AHCA),pursuant to Florida Statute 408.05,or any successor statute, located at the web site address www.ibddahealthgnder,00v may be accessed through the link provided on the Blue Cross and Blue Shield of Florida corporate web site at www.fioridablue.com. Third Party Beneficiary The terms and provisions of the Group Health Plan shall be binding solely upon,and Inure solely to the benefit of, Monroe County BOCC and Individuals coveted under the terms of this Benefit Booklet,and no other person shall have any rights, interest or claims thereunder,or under this Benefit Booklet,or be entitled to sue For a breach thereof as a third-party beneficiary or otherwise. Monroe County BOCC hereby specifically expresses its intent that health care Providers that have not entered into contracts with BCBSF to participate in BCBSF's Provider networks shall not be third-party beneficiaries under the terms of the Monroe County BOCC Group Health Plan or this Benefit Booklet. Customer Rewards Programs From time to time,we may offer programs 10 our customers that provide rewards for following the terms of the program. We will tell you about any available rewards programs In general mailings, member newsletters and/or on our website. Your-participation in these programs Is completely voluntary and will in no way affect the coverage available to you under this Benefit Booklet. We reserve the right to offer rewards In excess of 525 per year as well as the right to discontinue or modify any reward program features or promotional offers at any time without your consent. General Pmvlelone 21-3 Section 22: Definitions The following definitions are used In this Benefit 1. In the case of an In-Network Provider Booklet. Other definitions may be found In the located In Florida,this amount will be particular section or subsection where they are established In accordance with the used. applicable agreement between that Provider Accident means an unintentional,unexpected and BCBSF. event,other than the acute onset of a bodily 2. In the case of an In-Network Provider infirmity or disease,which results In traumatic located outside of Florida,this amount will injury. This term does not Include injuries generally be established in accordance with caused by surgery or treatment for disease or the negotiated price that the on-site Blue illness. Cross and/or Blue Shield Plan("Host Blue") passes on to us,except when the Host Blue Accidental Dental Injury means an injury to is unable to pass on Its negotiated price due sound natural teeth(not previously to the terms of its Provider contracts. See compromised by decay)caused by a sudden, the BlueCard(Out-of-State)Program unintentional,and unexpected event or force. section for more details. This term does not include injuries to the mouth, g In the case of Out-of-Network Providers structures within the oral cavity,or injuries to located In Florida who participate in the natural teeth caused by biting or chewing, Traditional Program,this amount will be surgery,or treatment fora disease or illness. established In accordance with the Administrative Services Only Agreement or applicable agreement between that Provider ASO Agreement means an agreement between and BCBSF. Monroe County BOCC and BCBSF. Under the 4. In the case of Out-of-Network Providers Administrative Services Only Agreement, located outside of Florida who participate in BCBSF provides claims processing and the BlueCard(Out-of-Stale)Traditional payment services,customer service,utilization Program,this amount will generally be review services and access to BCBSF's established in accordance with the NetworkBlue and BCBSF's network of negotiated price that the Host Blue passes Traditional Insurance Providers. on to us,except when the Host Blue Is Adverse Benefit Determination means any unable to pass on Its negotiated price due to denial,reduction or termination of coverage, the terms of its Provider contracts. See the benefits,or payment(in whole or in part)under BlueCard(Out-of-State)Program section for the Benefit Booklet with respect to a Pre-Service more details. Claim ore Post-Service Claim.Any reduction or 5. In the case of an Out-of-Network Provider termination of coverage,benefits,or payment in that has not entered into an agreement with odnnedgdn with a Concurrent Care Decision,as BCBSF to provide access to a discount from described in this section,shall also constitute an the billed amount of that Provider for the Adverse Benefit Determination. specific Covered Services provided to you, Allowed Amount means the maximum amount the Allowed Amount will be the lesser of that upon which payment will be based for Covered Provider's actual billed amount for the Services. The Allowed Amount may be changed specific Covered Services or an amount at any time without notice to you or your established by BCBSF that may be based consent. on several factors Including(but not Wrueuon 22.1 necessarily limited to):(I)payment for such Service is a Covered Service,All terms and Services under the Medicare and/or conditions included in your Booklet apply.You Medicaid programs;(II)payment open should refer to the"What is Covered?"3ectien of accepted for such Services by that Out-of- your Booklet and the Schedule of Benefits to Network Provider and/or by other Providers, determine what is covered and how much will be either in Florida or in other comparable markel(s),that BCBSF determines are Please specifically note that,in the case of an comparable to the Out-of-Network Provider Out-of-Network Provider that has not entered that provided the specific Covered Services into an agreement with BCBSF to provide (which may Include payment accepted by access to a discount from the billed amount of such Out-of-Network Provider and/or by that Provider,the Mowed Amount for particular other Providers as participating providers in Services is often substantially below the amount other provider networks of third-party payers billed by such Out-of-Network Provider for such which may include,for example,other Services. You will be responsible for any insurance companies and/or health difference between such Allowed Amount and maintenance organizations);(Ili)payment the amount billed for such Services by any such amounts which are consistent,as Out-of-Network Provider. determined by BCBSF,with BCBSF's Ambulance means a ground or water vehicle, provider network strategies(e.g.,does not airplane or helicopter properly licensed pursuant result In payment that encourages Providers to Chapter 401 of the Florida Statutes,or a participating In a BCBSF network to become similar applicable law In another state. non-participating);and/or,(iv)the cost of I ---providing the specific Covered Services. In Ambulatory Surgical Center means a facility the case of an Out-of-Network Provider that properly licensed pursuant to Chapter 395 of the has not entered into an agreement with Florida Statutes,or a similar applicable law of another Blue Cross and/or Blue Shield another state,the primary purpose of which is to organization to provide access to discounts provide elective surgical care to a patient, from the billed amount for the specific admitted to,and discharged from such facility Covered Services under the BlueCard(Out- within the same working day. of-State)Program,the Allowed Amount for Applied Behavior Analysis means the design, the specific Covered Services provided to implementation and evaluation of environmental you may be based upon the amount modifications,using behavioral stimuli and provided to BCBSF by the other Blue Cross consequences to produce socially significant and/or Blue Shield organization where the improvement In human behavior,Including,but Services were provided at the amount such not limited to,the use of direct observation, organization would pay non-participating measurement and functional analysis of the Providers In its geographic area for such relations between environment and behavior. Services. Approved Clinical Trial means a phase I, You may obtain an estimate of the Allowe4 phase II,phase III,or phase IV clinical trial that Amount for particular Services by calling thA is conducted in relation to the prevention, customer service telephone number Included In detection,or treatment of cancer or other Life- (his Booklet or on your Identification Card.The Threatening Disease or Condition and meets fact that we may provide you with such one of the following criteria: information does not mean that the particular paaalons 42 1. The study or investigation is approved or qualified individuals who have no interest In the funded by one or more of the following: outcome of the review. a. The National Institutes of Health. For purposes of this definition,the term'Life- b. The Centers for Disease Control and Threatening Disease or Condition'means any disease or condition from which the likelihood of Prevention. death is probable unless the course of the c. The Agency for Health Care Research disease or condition Is Interrupted. and Quality. Artificial Insemination(AI)means a medical d. The Centers for Medicare and Medicaid procedure in which sperm Is placed into the Services. female reproductive tract by a qualified health e. Cooperative group or center of any of care provider for the purpose of producing a the entitles described in clauses(I) pregnancy. through(Iv)or the Department of Autism Spectrum Disorder means any of the Defense or the Department of Veterans following disorders as defined In the diagnostic Affairs. categories of the International Classification of f. A qualified non-governmental research Diseases,Ninth Edition,Clinical Modification entity identified in the guidelines Issued (ICD-9 CM),or their equivalents in the most by the National Institutes of Health for recently published version of the American center support grants. Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders: g. My of the following if the conditions ----described in paragraph(2)are met: 1. Autistic disorder; I. The Department of Veterans Affairs. 2. Asper9er's syndrome; B. The Department of Defense. 3. Pervasive developmental disorder not otherwise specified;and ill. The Department of Energy. 4. Childhood Disintegrative Disorder. 2. The study or investigation is conducted under an investigational new drug Benefit Period means a consecutive period of application reviewed by the Food and Drug time,specified by BCBSF and the Group,in Administration. which benefits accumulate toward the satisfaction of Deductibles,out-of-pocket 3. The study or Investigation is a drug trial that maximums and any applicable benefit is exempt from having such an maximums. Your Benefit Period is listed on your Investigational new drug application. Schedule of Benefits,and will not be less than For a study or investigation conducted by a 12 months unless indicated as such. Department the study or Investigation must be Birth Center means a facility or institution,other reviewed and approved through a system of than a Hospital or Ambulatory Surgical Center, peer review that the Secretary determines:(1)to which is properly licensed pursuant to Chapter be comparable to the system of peer review of 383 of the Florida Statutes,ore similar studies and Investigations used by the National applicable law of another state,in which births Institutes of Health,and(2)assures unbiased are planned to occur away from the mother's review of the highest scientific standards by usual residence following a normal, uncomplicated,low-risk pregnancy. afnaonf 22-3 BlueCard(Out-of-State)Program means a acceptable related or unrelated donor,and may national Blue Cross and Blue Shield Association be derived from bone marrow,the circulating program available through Blue Cross and Blue blood,or a combination of bone marrow and Shield of Florida, Inc. Subject to any applicable circulating blood. If chemotherapy Is an integral BlueCard(Out-of-State)Program rules and part of the treatment Involving bone marrow protocols,you may have access to the Provider transplantation,the term"Bone Marrow discounts of other participating Blue Cross and/or Transplant"includes the transplantation as well Blue Shield plans. See the BlueCard(Out-of- as the administration of chemotherapy and the State)Program section for more details. chemotherapy drugs. The term"Bone Marrow Transplant"also includes any Services or BlueCard(Out-of-State)PPO Program means supplies relating to any treatment or therapy a national Blue Cross and Blue Shield involving the use of high dose or intensive dose Association program available through Blue chemotherapy and human blood precursor cells Cross and Blue Shield of Florida, Inc. Subject to and includes any and ell Hospital,Physician or any applicable BlueCard(Out-of-State)Program other health care Provider Health Care Services rules and protocols,you may have access to the which are rendered in order to treat the effects BlueCard(Out-of-State)PPO Program discounts of,or complications arising from,the use of high of other participating Blue Cross and/or Blue dose or intensive dose chemotherapy or human Shield plans. blood precursor cells(e.g., Hospital room and BlueCard(Out-of-State)Traditional Program board and ancillary Services). means a national Blue Cross end Blue Shield Calendar Year begins January 1st and ends Association program available through Blue December 31st. Cross and Blue Shield of Florida, Inc. Subject to - any applicable BlueCard(Out-of-State)Program Cardiac Therapy means Health Care Services rules and protocols, you may have access to the provided under the supervision of a Physician, BlueCard(Out-of-State)Traditional Program or an appropriate Provider trained for Cardiac discounts of other participating Blue Cross Therapy,for the purpose of aiding in the and/or Blue Shield plans. restoration of normal heart function in connection with a myocardial infarction, BlueCard(Out-of-State)PPO Program coronary occlusion or coronary bypass surgery. Provider means a Provider designated as a BlueCard(Outof-Stale)PPO Program Provider Certified Nurse Midwife means a person who by the Host Blue. is licensed pursuant to Chapter 464 of the Floods Statutes,or a similar applicable law of BlueCard(Out-of-State)Traditional Program another state,as an advanced nurse practitioner Provider means a Provider designated as a and who is certified to practice midwifery by the BlueCard(Outof-Slate)Traditional Program American College of Nurse Midwives. Provider by the Host Blue. Certified Registered Nurse Anesthetist Belie-Marrow Transplant means human blood means a person who is a properly licensed precursor cells administered to a patient to nurse who is a certified advanced registered restore normal hematdogical and immunological nurse practitioner within the nurse anesthetist functions following ablative or non-ablative category pursuant to Chapter 464 of the Florida therapy with curative or life-prolonging intent. Statutes,or a similar applicable law of another Human blood precursor cells may be obtained slate. from the patient in an autologous transplant,or an allogeneic transplant from a medicably 124 oefintlom Claim involving Urgent Care means any in a retail business;and 4)is staffed by at least request or application for coverage or benefits one masters level nurse(ARNP)who operates for medical care or treatment that has not yet under a set of clinical protocols that strictly been provided to you with respect to which the circumscribe the conditions the ARNP can treat. application of time periods for making non- Although no physician Is present at the urgent care benefit determinations:(1)could Convenient Care Center,medical oversight Is seriously jeopardize your fife or health or your based on a written collaborative agreement ability to regain maximum function;or(2)in the between a supervising physician and the ARNP. opinion of a Physician with knowledge of your Copayment means the dollar amount Condition,would subject you to severe pain that established solely by BCBSF-and Monroe I cannot be adequately m rendered. without the County BOCC which is required to be paid to a proposed Services being rendered. health care Provider by you at the time certain Coinsurance means your share of health care Covered Services are rendered by that Provider. expenses for Covered Services. After your Cost Share means the dollar or percentage Deductible requirement is met,a percentage of amount established solely by us,which must be the Allowed Amount will be paid for Covered paid to a health care Provider by you at the lime Services,as listed In the Schedule of Benefits. Covered Services are rendered by that Provider. The percentage you are responsible for Is your Cost Share may Include,but Is not limited to Coinsurance. Coinsurance,Copayment, Deductible and/or Per Concurrent Care Decision means a decision Admission Deductible(PAD)amounts. by us to deny,reduce,or terminate coverage, Applicable Cost Share amounts are identified In benefits,or payment(In whole or in part)with your Schedule of Benefits. respect to a course of treatment to be provided Covered Dependent means an Eligible over a period of time,or a specific number of Dependent who meets and continues to meet all treatments,IF we had previously approved or applicable eligibility requirements and who is authorized in writing coverage,benefits,or enrolled,and actually covered,under the Group payment for that course of treatment or number Health Plan other than as a Covered Plan or treatments. Participant(See the'Eligibility Requirements for As defined herein,a Concurrent Care Decision Dependent(s)'subsection of the"Eligibility for shall not include any decision to deny,reduce. Coverage"section). or terminate coverage,benefits,or payment under the personal case management Program Covered Person means a Covered Plan as desuibed in the"Blueprint For Health Participant or a Covered Dependent. Programs'section of this Benefit Booklet. Covered Plan Participant means an Eligible Condition means a disease,Illness,ailment, Employee or other Individual who meets and injury.or pregnancy. continues to meet all applicable eligibility requirements and who is enrolled,and actually Convenient Care Center means a properly covered,under this Benefit Booklet other than licensed ambulatory center that: 1)treats a as a Covered Dependent. limited number of common,low-Intensity illnesses when ready access to the patient's Covered Services means those Health Care primary physician is not possible;2)shares Services which meet the criteria listed in the clinical Information about the treatment with the "What Is Covered?"section. patient's primary physician;3)Is usually housed oraewns txa Custodial or Custodial Care means care that similar regulatory agency of another state)to serves to assist an individual in the activities of provide hemodialysis and peritoneal dialysis daily living,such as assistance in walking, services and support. getting in and out of bed,bathing,dressing, Dietitian means a person who is properly feeding,and using the toilet preparation of licensed pursuant to Florida law or a similar special diets,and supervision of medication that applicable law of another stele to provide usually can be self-administered. Custodial nutrition counseling for diabetes outpatient self- Care essentially is personal care that does not management services. require the continuing attention of trained medical or paramedical personnel. In Durable Medical Equipment means equipment determining whether a person is receiving furnished by a supplier or a Home Health Custodial Care,consideration Is given to the Agency that: 1)can withstand repeated use; frequency,Intensity and level of care end 2)is primarily and customarily used to serve a medical supervision required and furnished. A medical purpose;3)not for comfort or determination that care received is Custodial is convenience;4)generally is not useful to an not based on the patient's diagnosis,type of individual in the absence of a Condition;and Condition,degree of functional limitation,or 5)Is appropriate for use in the home. rehabilitation potential. Durable Medical Equipment Provider means a Deductible means the amount of charges,up to person or entity that is properly licensed,if the Allowed Amount,for Covered Services that applicable, under Florida law(or a similar are your responsibility. The term, Deductible, applicable law of another state)to provide home does not include any amounts you are medical equipment,oxygen therapy services,or responsible for in excess of the Allowed Amount, dialysis supplies in the patient's home under a or any Coinsurance/Copay amounts,if Physician's prescription. applicable. Effective Date means,with respect to Detoxification means a process whereby an individuals covered under this Benefit Booklet, alcohol or drug intoxicated,or alcohol or drug 12:01 a.m.on the date Monroe County BOCC dependent,Individual is assisted through the specifies that the coverage will commence as period of time necessary to eliminate,by further described In the"Enrollment and metabolic or other means,the intoxicating Effective Date of Coverage"section of this alcohol or drug,alcohol or drug dependent Benefit Booklet. factors or alcohol in combination with drugs as Eligible Dependent means an individual who determined by a licensed Physician or Psychologist,while keeping the physiological meets and continues to meet all of the eligibility risk to the individual at a minimum. requirements described In the Eligibility Requirements for Dependent(s)subsection of Diabetes Educator means a person who is the Eligibility for Coverage section In this Benefit properly certified pursuant to Florida law,or a Booklet,and is eligible to enroll as a Covered similar applicable law of another stale,to Dependent. supervise diabetes outpatient saH-management Eligible Employee means an active employee training and educational services. or retiree_who meets and continues to meet all Dialysis Center means an outpatient facility of the eligibility requirements described in the certified by the Centers for Medicare and Eligibility Requirements for Covered Plan Medicaid Services(CMMS)and the Florida Participant subsection of the Eligibility for Agency for Health Care Administration(or a Coverage section in the Benefit Booklet and is 22-6 DNNuwrs eligible to enroll as a Covered Plan Participant. Experimental or Investigational means any Any individual who is an Eligible Employee is not evaluation,treatment,therapy,or device which a Covered Plan Participant unlit such Individual Involves the application,administration or use,of has actually enrolled with,and been accepted procedures,techniques,equipment,supplies, for coverage as a Covered Plan Participant by products,remedies,vaccines,biological Monroe County BOCC. products,drugs,pharmaceuticals,or chemical compounds If,as determined solely by BCBSF Emergency Medical Condition means a or Monroe County BOCC: medical or psychiatric Condition or an injury manifesting itself by acute symptoms of 1. such evaluation,treatment,therapy,or sufficient severity(including severe pain)such device cannot be lawfully marketed without that a prudent layperson,who possesses an approval of the United States Food and average knowledge of health and medicine, Drug Administration or the Florida could reasonably expect the absence of Department of Health and approval for Immediate medical attention to result in a marketing has not,In fact,been given at the condition described In clause(I),(II),or(III)of time such is furnished to you;or Section 1867(ex1)(A)of the Social Security Act. 2. such evaluation, treatment,therapy,or Emergency Services means,with respect to an device is provided pursuant to a written Emergency Medical Condition: protocol which describes as among its objectives the following: determinations of 1. a medical screening examination(as safety,efficacy,or efficacy In comparison to required under Section 1867 of the Social the standard evaluation,treatment,therapy, Security Act)that Is within the capability of or device;or tea emergency department of a Hospital, 3. such evaluation,treatment,therapy,or including ancillary Services routinely device is delivered or should be delivered available to the emergency department to subject to the approval and supervision of evaluate such Emergency Medical an institutional review board or other entity Condition;and as required and defined by federal 2. within the capabilities of the staff and regulations;or facilities available at the hospital,such 4. credible scientific evidence shows that such further medical examMaton and treatment evaluation,treatment,therapy,or device is as are required under Section 1867 of such the subject of an ongoing Phase I or II Act to Stabilize the patient. clinical Investigation,or the experimental or Endorsement means an amendment to the research arm of a Phase III clinical Group Health Plan or this Booklet. investigation,or under study to determine: maximum tolerated dosage(s),toxicity, Enrollment Date means the date of enrollment safety,efficacy,or efficacy as compared of the individual under the Group Health Plan or, with the standard means for treatment or if earlier,the first day of the Waiting Period of diagnosis of the Condition In question;or such enrollment. 5. credible scientific evidence shows that the Enrollment Forms means those forms, consensus of opinion among experts Is that electronic(where available)or paper,which are further studies,research,or clinical used to maintain accurate enrollment files under investigations are necessary to determine: this Benefit Booklet. maximum tolerated dosage(s),toxicity, safety,efficacy,or efficacy as compared x2-T pKnitlore with the standard means for treatment or 5. the written informed consent used by the diagnosis of the Condition In question;or treating Physician or institution or by another Physician or institution studying substantially 6. credible scientific evidence shows that such the same evaluation,treatment,therapy,or evaluation,treatment,therapy,or device has device;or not been proven safe and effective for treatment of the Condition in question,as 6. the records(including any reports)of any evidenced in the most recently published Institutional review board of any Institution Medical Literature in the United States, which has reviewed the evaluation, Canada,or Great Britain,using generally treatment,therapy,or device for the accepted scientific,medical,or public health Condition in question. methodologies or statistical practices;or Note: Health Care Services which are 7. there is no consensus among practicing determined by BCBSF to be Experimental or Physicians that the treatment,therapy,or Investigational are excluded(see the"What device is safe and effective for the Condition Is Not Covered?"section). In determining In question;or whether a Health Care Service is Experimental or investigational,BCBSF may 8. such evaluation,treatment,therapy,or also rely on the predominant opinion among device Is not the standard treatment, experts,as expressed in the published therapy,or device utilized by practicing authoritative literature,that usage of a Physicians in treating other patients with the particular evaluation,treatment,therapy,or same or similar Condition. device should be substantially confined to "Credible scientific evidence"shall mean(as research settings or that further studies are determined by BCBSF): necessary in order to define safety,toxicity, 1. records maintained by Physicians or effectiveness,or effectiveness compared Hospitals rendering care or treatment to you with standard alternatives. or other patients with the same or similar FDA means the United States Food and Drug Condition; Administration. 2. reports,articles,or written assessments in Foster Child means a person who Is placed In authoritative medical and scientific literature your residence and care under the Foster Care published in the United States,Canada,or Program by the Florida Department of Health& Great Britain; Rehabilitative Services in compliance with 3. published reports,articles,or other literature Florida Statutes or by a similar regulatory of the United States Department of Health agency of another state in compliance with that and Human Services or the United States state's applicable laws. Public Health Service,including any of the Gamete Intrafallopian Transfer(GIFT)means National institutes of Health,or the United the direct transfer of a mixture of sperm and States Office of Technology Assessment; eggs into the fallopian tube by a qualified health 4. the written protocol or protocols relied upon care provider. Fertilization takes place inside by the treating Physician or Institution or the the tube. protocols of another Physician or institution studying substantially the same evaluation, Generally Accepted Standards of Medical treatment,therapy,or device; Practice means standards that are based on credible scientific evidence published In peer- reviewed medical literature generally recognized 1t-0 Definitions by the relevant medical community,Physician personal care Services provided on an Specialty Society recommendations,and the intermittent or part-time basis directly by(or views of Physicians practicing In relevant clinical indirectly through)a Home Health Agency In areas and any other relevant factors. your home or residence. For purposes of this definition,a Hospital,Skilled Nursing Facility, Gestational Surrogate means a woman, nursing home or other facility will not be regardless of age,who contracts,orally or In considered an individuai's home or residence. wilting,to become pregnant by means of assisted reproductive technology without the use Hospice means a public agency or private of an egg from her body. organization which is duly licensed by the State of Florida under applicable law,or a similar Gestational Surrogacy Contract or applicable law of another state,to provide Arrangement means an oral or written hospice services. In addition.such licensed agreement,regardless of the state or jurisdiction entity must be principally engaged in providing where executed, between the Gestational pain relief, symptom management,and Surrogate and the Intended parent or parents. supportive services to terminally ill persons and Group means the employer,labor union,trust, their families. association,partnership,or corporation, Hospital means a facility property licensed whichdepartment,coverage other organization or entity through pursuant to Chapter 395 of the Florida Statutes, which coverage and benefits under this Benefit or a similar applicable law of another state,that: Booklet are made available to you,and through offers services which are more intensive than which you and your Covered Dependents those required for room,board,personal become entitled to coverage and benefits for the services an targen nursing care;personal ffers t)pvertxLSarvicesciescribed herein facilities and beds for use beyond 24 hours;and Group Health Plan or Group Plan means the regularly makes available at least clinical plan established and maintained by Monroe laboratory services,diagnostic x-ray services County BOCC for the provision of health care and treatment facilities for surgery or obstetrical coverage and benefits to the individuals covered care or other definitive medical treatment of under this Benefit Booklet. similar extent. Health Care Services or Services includes The term Hospital does not include: an treatments,therapies,devices,procedures. Ambulatory Surgical Center;a Skilled Nursing techniques,equipment,supplies,products, Facility; a stand-alone Birthing Center,a remedies,vaccines,biological products,drugs, Psychiatric Facility;a Substance Abuse Facility; pharmaceuticals,chemical compounds,and a convalescent,rest or nursing home;or a other services rendered or supplied,by or at the facility which primarily provides Custodial, direction of,Providers. educational,or Rehabilitative Therapies. Nome Health Agency means a properly Note: If services specifically for the licensed agency or organization which provides treatment of a physical disability are health services In the home pursuant to Chapter provided in a licensed Hospital which is 400 of the Florida Statutes,or a similar accredited by the Joint Commission on the applicable law of another state. Accreditation of Health Care Organizations, the American Osteopathic Association,or Home Health Care or Home Health Care the Commission on the Accreditation of Services means Physician-directed Rehabilitative Facilities,payment for these professional,technical and related medical and services will not be denied solely because nefineom 22A such Hospital lacks major surgical facilities Covered Services are rendered,the Provider Is and is primarily of a rehabilitative nature. an In-Network Provider under the terms of this Recognition of these facilities does not Booklet. expand the scope of Covered Services- It In-Network Provider means any health care only expands the setting where Covered Provider who,at the time Covered Services Services can be performed for coverage were rendered to you,was under contract with purposes. BCBSF to participate in BCBSF's NetworkBlue Identification(ID)Card means the card(s) and included in the panel of providers issued to Covered Plan Participants under the designated by BCBSF as"In-Network"for your BlueOptions Group Health Plan. The card is not specific plan. (Please refer to your Schedule of transferable to another person. Possession of Benefits). For payment purposes under this such card In no way guarantees that a particular Benefit Booklet only,the term In-Network Individual is eligible for,or covered under,this Provider also refers,when applicable,to any Benefit Booklet, health care Provider located outside the state of Florida who or which,at the time Health Care Independent Clinical Laboratory means a Services were rendered to you,participated as a laboratory properly licensed pursuant to Chapter BlueCard(Out-of-Stale)PPO Program Provider 483 of the Florida Statutes,or a similar under the Blue Cross Blue Shield Association's applicable law of another state,where BlueCard(Out-of-State)Program. examinations are performed on materials or specimens taken from the human body to Intensive Outpatient Treatment means provide Information or materials used in the treatment in which an individual receives at least diagnosis,prevention,or treatment of a 3 clinical hours of institutional care per day(24- CondltTon. hour period)for at least 3 days a week and returns home or is not treated as an Inpatient Independent Diagnostic Testing Facility during the remainder or that 24-hour period. A means a facility,independent of a Hospital or Hospital shall not be considered a"home"for Physician's office,which Is a fixed location,a purposes of this definition. mobile entity,or an individual non-Physician practitioner where diagnostic tests are In Vitro Fertilization(IVF)means a process In performed by a licensed Physician or by which an egg and sperm we combined in a licensed,certified non-Physician personnel laboratory dish to facilitate fertilization. If under appropriate Physician supervision. An fertilized,the resulting embryo is transferred to Independent Diagnostic Testing Facility must be the woman's uterus. appropriately registered with the Agency for Licensed Practical Nurse means a person Health Care Administration and must comply properly licensed to practice practical nursing with all applicable Florida law or laws of the State In which it operates. Further,such an pursuant to Chapter 464 of the Florida at Statues, entity must meet BCBSF's criteria for eligibility or a similar applicable law of another stat as an Independent Diagnostic Testing Facility. Massage Therapist means a person properly licensed to practice Massage,pursuant to In-Network means,when used in reference to Chapter 480 of the Florida Statutes,or a similar Covered Services,the level of benefits payable applicable law of another state. to an In-Network Provider as designated on the Schedule of Benefits under the heading"In- Massage or Massage Therapy means the Network". Otherwise, In-Network means,when manipulation of superficial tissues of the human used in reference to a Provider,that,at the lime 2210 Carillons body using the hand,foot, arm,or elbow. For an alternative location(e.g.,office vs. purposes of this Benefit Booklet,the term Inpatient),and/or an alternative Service or Massage or Massage Therapy does not include sequence of Services at least as likely to the application or use of the following or similar produce equivalent therapeutic or diagnostic techniques or items for the purpose of aiding in results as to the diagnosis or treatment of the manipulation of superficial tissues: hot or your illness,injury,disease or symptoms. cold packs;hydrotherapy;colonic irrigation; When determining whether a Service is not thermal therapy;chemical or herbal preparations;paraffin baths;infrared light: more costly than the same or similar Service as ultraviolet light:Hubbard tank;or contrast baths. referenced above,we may, but are not required to,take into consideration various factors Mastectomy means the removal of all or part of Including, but not limited to,the following: the breast for Medically Necessary reasons as a. the Allowed Amount For Service at the I determined by a Physician. location for the delivery of the Service Medical Literature means scientific studies versus an alternate setting; published in a United States peer-reviewed b. the amount we have to pay to the I national professional journal. proposed particular Provider versus the Medical Pharmacy Physician-administered Mowed Amount for a Service by Prescription Drugs which are rendered in a another Provider including Providers of Physician's office. the same and/or different licensure IMedically Necessary or Medical Necessity and/or specialty;and/or; means that with respect to a Health Care c. an analysis of the therapeutic and/or Service,a Provider,exercising prudent clinical diagnostic outcomes of an alternate judgment,provided,or is proposing or treatment versus the recommended or recommending to provide the Health Care performed procedure including a Service to you for the purpose of preventing, comparison to no treatment. Any such analysis may include the short and/or evaluating,diagnosing or treating an Illness, longterm health outcomes of the injury,disease or its symptoms,and that the recommended or performed treatment Health Care Service was/is: versus alternate treatments including an 1. in accordance with Generally Accepted analysis of such outcomes as the ability Standards of Medical Practice; of the proposed procedure to treat comarbidities,time to disease 2. clinically appropriate, in terms of type, recurrence,the likelihood of additional frequency,extent, site of Service,duration, Services in the future,etc. and considered effective for your illness, Injury,or disease or symptoms; Note: The distance you have to travel to receive _ a Health Care Service,time off from work, 3 not primarily for your convenience,your overall recovery time,etc.are not factors that we family's convenience, your caregiver's are required to consider when evaluating convenience or that of your Physician or whether or not a Health Care Service is not other health care Provider,and more costly than an alternative Service or sequence of Services. 4, not more costly than the same or similar Service provided by a different Provider,by Reviews we perform of Medical Necessity may way of a different method of administration, be based on comparative effectiveness nnl peANlime research,where available,or on evidence Statutes,or a similar applicable law of another showing lack of superiority of a particular slate. This professional may be a clinical social Service or lack of difference in outcomes with worker,mental health counselor or marriage and respect to a particular Service. In performing family therapist. A Mental Health Professional Medical Necessity reviews,we may take Into does not Include members of any religious consideration and use cost data which may be denomination who provide counseling services. proprietary. Mental and Nervous Disorder means any It is Important to remember that any review of disorder listed in the diagnostic categories of the Medical Necessity by us is solely for the purpose International Classification of Disease(ICD-9 of determining coverage or benefits under this CM or ICD 10 CM),or their equivalents in the Booklet and not for the purpose of most recently published version of the American recommending or providing medical care. In this Psychiatric Association's Diagnostic and respect,we may review specific medical facts or Statistical Manual of Mental Disorders, information pertaining to you. Any such review, regardless of the underlying cause,or effect,of however, is strictly for the purpose of the disorder. determining,among other things,whether a Service provided or proposed meets the Midwife means a person properly licensed to definition of Medical Necessity in this Booklet as practice midwifery pursuant to Chapter 487 of determined by us. In applying the definition of the Florida Statutes,or a similar applicable law Medical Necessity In this Booklet,we may apply of another state. our coverage and payment guidelines then in effect. You are free to obtain a Service even if NetworkBlue means,or refers to,the preferred we deny coverage because the Service is not provider network established and so designated Medically Necessary; however,you will be solely by BCBSF which is available to Individuals responsible for paying for the Service. covered under this Benefit Booklet. Please note Medicare means the federal health Insurance that BCBSF's Preferred Patient Care(PPC) preferred provider network Is not available to provided under Title nt of the Social Security individuals covered under this Benefit Booklet. Act and all amendments s t thereto. Occupational Therapist means a person Medication Guide for the purpose of this properly licensed to practice Occupational Benefit Booklet means the guide then in effect Therapy pursuant to Chapter 468 of the Florida Issued by us where you may find information Statutes,or a similar applicable law of another about Specialty Drugs,Prescription Drugs that state. require prior coverage authorization and Self- Administered Prescription Drugs that may be Occupational Therapy means a treatment that covered under this plan. follows an illness or Injury and Is designed to Note: The Medication Guide is subject to help a patient team to use a newly restored or change at any time. Please refer to our website previously impaired function. at yiww.floridablue.com for the most current Orthotic Device means any rigid or semi-rigid guide or you may call the customer service device needed to support a weak or deformed phone number on your Identification Card for body part or restrict or eliminate body current information. movement. Mental Health Professional means a person Outwf•Network means,when used in reference properly licensed to provide mental health to Covered Services,the level of benefits Services,pursuant to Chapter 491 of the Florida payable to an Out-of-Network Provider as n.12 eKmitloro designated on the Schedule of Benefits under care Hospital,or any separately organized unit the heading"Out-or-Network". Otherwise,Out- of a Hospital,which provides comprehensive of-Network means,when used In reference to a medical rehabilitation inpatient services,or Provider,that,at the time Covered Services are rehabilitation outpatient services,including,but rendered,the Provider Is not en In-Network not limited to,a Class III"specialty rehabilitation Provider under the terms of this Booklet. hospitar described In Chapter 59A,Florida Administrative Code or the similar law or laws of Out-of-Network Provider means a Provider who,at the time Health Care Services were another state. rendered: Pain Management includes,but is not limited I. did not have a contract with us to participate to,Services for pain assessment,medication, in NetworkBlue but was participating in our physical therapy, biofeedback,andfor Traditional Program;or counseling. Pain rehabilitation programs ere 2. did not have a contract with a Host Blue to programs featuring multidisciplinary Services participate in its local PPO Program for directed toward helping those with chronic pain purposes of the BlueCard(Out-of-State) to reduce or limit their pain. PPO Program but was participating,for Partial Hospitalization means treatment in purposes of the BlueCard(Out-of-State) which an individual receives at least 6 clinical Program, as a BlueCard(Out-of-State) hours of institutional care per day(24-hour Traditional Program Provider;or period)for at least 5 days per week and returns 3. did have a contract to participate in home or is not treated as en Inpatient during the NetworkBlue but was not included in the remainder of that 24-hour period. A Hospital panel of Providers designated by us to be shall not be considered a"home"for purposes of In-Network for your Plan;or this definition. 4. did not have a contract with us to participate Physical Therapy means the treatment of in NetworkElue or our Traditional Program; disease or injury by physical or mechanical Or means as defined In Chapter 486 of the Florida 5. did not have a contract with a Host Blue to Statutes or a similar applicable law of another participate for purposes of the BlueCard slate. Such therapy may include traction,active (Out-of-State)Program as a BlueCard(Out- or passive exercises,or heat therapy. of State)Traditional Program Provider. Physical Therapist means a person properly Outpatient Rehabilitation Facility means an licensed to practice Physical Therapy pursuant entity which renders,through providers properly to Chapter 486 of the Florida Statutes,or a licensed pursuant to Florida law or the similar similar applicable law of another state. law or laws of another state: outpatient physical therapy;outpatient speech therapy;outpatient Physician means any Individual who is properly occupational therapy;outpatient cardiac licensed by the state of Florida,or a similar rehabilitation therapy;and outpatient Massage applicable law of another state,as a Doctor of for the primary purpose of restoring or improving Medicine(M.D.),Doctor of Osteopathy(0.0.), a bodily function impaired or eliminated by a Doctor of Podiatry(D.P.M.),Doctor of Condition. Further,such an entity must meet Chiropractic(D.C.),Doctor of Dental Surgery or BCBSF's criteria for eligibility as an Outpatient Dental Medicine(D.D.S.or D.M.D.),or Doctor of Rehabilitation Facility.The term Outpatient Optometry(OD.). Rehabilitation Facility,as used herein, shall not include any Hospital including a general acute oeanuaa 22.13 Physician Assistant means a person properly amount-af-t' licensed pursuant to Chapter 458 of the Florida severed-under-6redn"`'^r-; '7`r Statutes,or a similar applicable law of another ProsthettstlOrthotist means a person or entity state. that is properly licensed,If applicable,under Physician Specialty Society means a United Florida law,or a similar applicable law of States medical specialty society that represents another state,to provide services consisting of diplomates certified by a board recognized by the design and fabrication of medical devices the American Board of Medical Specialties. such as braces,splints,and artificial limbs prescribed by a Physician. Post-Service Claim means any paper or electronic request or application for coverage, Prosthetic Device means a device which benefits,or payment for a Service actually replaces all or part of a body part or an internal provided to you(not just proposed or body organ or replaces all or part of the recommended)that is received by us on a functions of a permanently inoperative or properly completed claim Form or electronic malfunctioning body part or organ. format acceptable to us in accordance with the provider means any facility, person or entity provisions of this section. recognized for payment by BCBSF under this Pre-Service Claim means any request or Booklet. application for coverage or benefits for a Service Psychiatric Facility means a facility properly that has not yet been provided to you and with respect to which the terms of the Benefit Booklet licensed under Florida law,or a similar condition payment for the Service(in whole or in applicable law of another state,to provide for the part)on approval by us of coverage or benefits Medically Necessary care and treatment of for the Service before you receive it. A Pre- Mental and Nervous Disorders, For purposes of Service Claim may be a Claim Involving Urgent this Booklet,a ' . s hialr Care. As defined herein,a Pre-Service Claim facility is not a Hospital or a Substance Abuse shall not include a request for a decision or Facility,as defined herein. opinion by us regarding coverage,benefits,of Psychologist means a person properly licensed payment Fora Service that has not actually been to practice psychology pursuant to Chapter 490 rendered to you If the terms of the Benefit of the Florida Statutes,or a similar applicable Booklet do not require(or condition payment law of another state. upon)approval by us of coverage or benefits for the Service before it Is received. Registered Nurse means a person properly licensed to practice professional nursing Prescription Drug means any medicinal pursuant to Chapter 464 of the Florida Statutes, substance,remedy,vaccine,biological product, or a similar applicable law of another state. drug,pharmaceutical or chemical compound which can only be dispensed with a Prescription Registered Nurse First Assistant(RNFA) andlor which is required by state law to bear the means a person properly licensed to perform following statement or similar statement on the surgical first assisting services pursuant to label: "Caution: Federal law prohibits Chapter 464 of the Florida Statutes or a similar dispensing without a Prescription". applicable law of another state. PNer{Corwurren Rehabilitation Services means Services for the purpose of restoring function lost due to illness, M .su Dopendo ,sanbmg4e-BCBSFas-pwal-atthe injury or surgical procedures including but not $-14 oofmiumr limited to cardiac rehabilitation, pulmonary days oer week,which must be actively rehabilitation, Occupational Therapy,Speech supervised by an attending physician. Therapy,Physical Therapy and Massage • Ability to assess and recognize withdrawal Therapy. complications that threaten life or bodily Rehabilitative Therapies means therapies the function and to obtain needed Services primary purpose of which is to restore or either on site or externally- improve bodily or mental functions impaired or • Is supervised by an on-site Physician 24 eliminated by a Condition,and include,but are hours per day and 7 days per week with not limited to,Physical TherSpeech evidence of close and freeuent observation. Therapy, Pain Management,meat, pulmonary therapy or Cardiac Therapy. Residential Treatment Services means treatment in which an Individual is admitted by a Residential Treatment Facility means a facility Physician overnight to a Hospital,Psychiatric properly licensed under Florida law or a similar Hospital or Residential Treatment Facility and applicable law of another stale,l0 provide care receives daily face to face treatment by a Mental and treatment of Mental and Nervous Disorders Health Professional for at least 8 hours per day and Substance Dependency and meets all of the each day. The Physician must perform the Jollowing reoulremenis: admission evaluation with documentation and • Has Mental Health Professionals on-site 24 treatment orders within 48 hours and provide hours Der day and 7 days per week evaluations at least weekly with documentation • Provides access to necessary medical A multidisciplinary treatment plan must be services 24 hours per day and 7 days per developed within 3 days of admission and must week be updated weekly. • Provides access to at least weekly sessions Self-Administered Prescription Drug means with a behavioral health professional fully an FDA-approved Prescription Drug that you licensed for independent practice for may administer to yourself,as recommended by individual psychotherapy' a Physician. • Has individualized active treatment plan Skilled Nursing Facility means an institution or directed toward the alleviation of the part thereof which meets BCBSF's criteria for impairment that caused the admission eligibility as a Skilled Nursing Facility and which: 1)is licensed as a Skilled Nursing Facility by the • Provides a level of skilled intervention state of Florida or a similar applicable law of consistent with patient risk' another state;and 2)is accredited as a Skilled • Is not a wilderness treatment grogram or Nursing Facility by the Joint Commission on any such related or similar Drooram,school Accreditation of Healthcare Organizations or recognized as a Skilled Nursing Facility by the and!or education service. Secretary of Health and Human Services of the With regard to Substance Dependency United States under Medicare, unless such treatment,in addition to the above,must meet accreditation or recognition requirement has the following: been waived by BCBSF. • If Detoxification Services are necessary Sound Natural Teeth means teeth that are provides access to necessary on-site whole or properly restored(restoration with medical services 24 hours Der day and 7 amalgams,resin or composite only);are without DeRM1Ronr II•15 impairment,periodontal.or other conditions;and Dependency. For the purposes of this Booklet a are not in need of Services provided for any Substance Abuse Facility Is not a Hospital or a mason other than an Accidental Dental Injury. Psychiatric Facility,as defined herein. Teeth previously restored with a crown,inlay, Substance Dependency means a Condition onlay,or porcelain restoration,or treated with where a person's alcohol or drug use injures his endodonUcs,are not Sound Natural Teeth. or her health:interferes with his or her social or Specialty Drug means an FDA-approved economic functioning;or causes the individual to Prescription Drug that has been designated, lose self-control. solely by us,as a Specialty Drug due to special Traditional Program means,or refers to, handling, storage,training,distribution BCBSF's provider contracting programs called requirements and/or management of therapy. Payment for Physician Services(PPS)and Specialty Drugs may be Provider administered Payment for Hospital Services(PHS). For or self-administered and are Identified with a purposes of this Benefit Booklet,the term special symbol in the Medication Guide. Traditional Program also refers.when Specialty Pharmacy means a Pharmacy that applicable,to the traditional Provider contracting has signed a Participating Pharmacy Provider programs of other Blue Cross and/or Blue Shield Agreement with us to provide specific organizations as designated under the Blue Prescription Drug products, es determined by Cross and Blue Shield Association's BlueCard us. In-Network Specialty Pharmacies are listed Program. in the Medication Guide. Traditional Program Providers means,or Speech Therapy means the treatment of refers to,those health care Providers who are speech and language disorders by a Speech not NetworkBlue Providers,but who, or which,at Therapist including language assessment and the time you received Services from them were language restorative therapy services. participating in the Traditional Program. For Purposes of payment under this Benefit Booklet Stabilize shall have the same meaning with only,the term Traditional Program Provider also regard to Emergency Services as the term Is refers,when applicable,to any health care defined in Section 1867 of the Social Security Provider located outside the state of Florida who Act. or which,at the time Health Care Services were ' Speech Therapist means a person property rendered to you,participated as a BlueCard licensed to practice Speech Therapy pursuant to Traditional Provider under the Blue Cross and Chapter 468 of the Florida Statutes,or a similar Blue Shield Association's BlueCard Program. applicable law of another state. Traditional providers are considered out of network for benefit calculation purposes; Standard Reference Compendium means: however,does not balance bill the memberT„ 1)the United Slates Pharmacopoeia Drug Information;2)the American Medical Urgent Care Center means a facility properly Association Drug Evaluation;or 3)the American licensed that 1)is available to provide Services Hospital Formulary Service Hospital Drug to patients at least 60 hours per week with at Information, least twenty-five(25)of those available hours after 5:00 p.m.on weekdays or on Saturday or Substance Abuse Facility means a facility Sunday:2)posts instructions for Individuals properly licensed under Florida law,or a similar seeking Health Care Services,in a conspicuous applicable law of another state,to provide public place,as to where to obtain such necessary care and treatment for Substance Services when the Urgent Care Center is 22-16 mefiNlbne 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 andfor federal laws and regulations. For purposes of this Benefit Booklet,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 Monroe County BOCC which must be met by an Individual before that Individual becomes eligible for coverage under this Benefit Booklet. Zygotelntrafalloplan Transfer(ZIFT)means a process in which an egg Is fertilized In the laboratory and the resulting zygote is transferred to the fallopian tube at the pronuclear stage (before cell division takes place). The eggs are retrieved and fertilized on one day and the zygote Is transferred the following day. oenmuon, 2247 Qualified Medical Child Support Orders Disclaimer Qualified Medical Child Support Orders-The Plan will provide benefits as required by any Qualified Medical Child Support Order (MCSO). A MCSO can be either:1) A Qualified Medical Child Support Order (MCSO)that satisfies the requirements of Section 609(a)of ERISA;or 2)A National Medical Support Notice(NMSN)that selis0eathe requirements of Section 190$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. oumumer