Item L13County of Monroe
A
BOARD OF COUNTY COMMISSIONERS
Mayor George Neugent, District 2
The Florida. Key
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Mayor Pro Tem David Rice, District 4
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Danny L. Kolhage, District I
Heather Carruthers, District 3
Sylvia J. Murphy, District 5
County Commission Meeting
April 12, 2017
Agenda Item Number: L.13
Agenda Item Summary #2832
BULK ITEM: No DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez- Gonzalez (305)
292 -4448
N/A
AGENDA ITEM WORDING: Discussion, direction, and approval of the 2017 Blue Options
Benefit Booklet for Covered Plan Participants of the Monroe County BOCC Group Health Plan
ITEM BACKGROUND: Each year, Florida Blue (FB) prepares a Benefit Booklet, outlining terms
of coverage for the Monroe County BOCC health plan, including mandates. FB sends the Benefit
Booklet to Monroe County staff for review prior to publication.
In December 2016, Florida Blue (FB) forwarded a draft Benefit Booklet covering plan year 2017 to
County Staff. The 2017 draft Benefit Booklet added the following language to the list of services
that would be covered in Section 2, Paragraph 6 (pages 2 -18): 6. Gender reassignment surgery and
Services related to gender dysphoria or gender transition are covered. The language was added by
Florida Blue to comply with Section 1557 of the Affordable Care Act, which had been issued by
federal Health and Human Services (HHS) during 2016 and went into effect on July 18, 2016. The
regulation was in force at the time that Florida Blue sent the draft Benefit Booklet to County staff for
review.
On December 31, 2016 (shortly after FB sent the booklet to the County for review), a federal District
Court judge issues an order, enjoining HHS from enforcing its regulation, on the grounds that the
regulation violated (a) the Administrative Procedure Act, and (b) the Religious Freedom Restoration
Act. HHS had not appealed the ruling.
The coverage, if added, would be new, i.e., the paragraph does not exist in the 2016 Booklet, which
is the booklet in circulation. Of course, Monroe County has the option of agreeing to cover the
surgery and related services described in Paragraph 6, just as it has the option to amend the plan to
pay for any of the services currently in Section 3 ( "What is Not Covered ") (e.g., cosmetic surgery).
The potential cost to the Plan of covering the cost of gender reassignment surgery and related
services is unknown.
The County's Options
The County has the following options:
1. Do not add the language now, until the appeal is concluded. The length of time the appeal
will take is unknown, but it likely to be within a year unless appealed further. HHS cannot
enforce its regulation until the appeal is concluded (in its favor).
2. Amend the plan to cover the surgeries and services described in Paragraph 6 now.
PREVIOUS RELEVANT BOCC ACTION: Plan Booklet approved by BOCC annually.
CONTRACT /AGREEMENT CHANGES:
N/A
STAFF RECOMMENDATION: Based on our attorney's recommendation, staff recommends
approval excluding services covered under Section 1557 of the Affordable Care Act.
DOCUMENTATION:
2017 Blue Options Benefit Booklet for the Monroe BOCC Group Health Plan
PLAN DOCUMENT LANGUAGE REGARDING SECTION 1557
FINANCIAL IMPACT:
Effective Date:
Expiration Date:
Total Dollar Value of Contract:
Total Cost to County:
Current Year Portion:
Budgeted:
Source of Funds:
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing:
Grant:
County Match:
Insurance Required:
Additional Details:
If yes, amount:
REVIEWED BY:
Christine Hurley Completed
Budget and Finance Completed
Cynthia Hall Completed
Maria Slavik Completed
03/28/2017 1:59 PM
03/28/2017 2:35 PM
03/28/2017 3:02 PM
03/28/2017 3:04 PM
Kathy Peters Completed 03/28/2017 8:18 PM
Board of County Commissioners Pending 04/12/2017 9:00 AM
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) 352 -2583
B0611 — Plan 03559
Divisions — 001, 002, C01, R01, R02
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: Claims Processing ................................................... ............................... 17 -1
Section 18: Relationship Between the Parties ............................ ............................... 18 -1
Section 19: General Provisions .................................................. ............................... 19 -1
Section 20: Definitions ................................................................ ............................... 20 -1
Table of Contents
Section 1: How to Use Your Benefit Booklet
This is your Benefit Booklet ( "Booklet "). It
describes your coverage, benefits, limitations
and exclusions for the self- funded Group Health
Benefit Plan ( "Group Health Plan" or "Group
Plan ") established and maintained by Monroe
County Board of County Commissioners.
be coordinated with other policies or plans;
and the Group Health Plan's subrogation
rights and right of reimbursement.
You will need to refer to the Schedule of
Benefits to determine how much you have to
pay for particular Health Care Services.
The sponsor of your Group Health Plan has
contracted with Blue Cross Blue Shield of
Florida, Inc. ( BCBSF), under an Administrative
Services Only Agreement ( "ASO Agreement "),
to provide certain third party administrative
services, including claims processing, customer
service, and other services, and access to
certain of its Provider networks. BCBSF
provides certain administrative services only and
does not assume any financial risk or obligation
with respect to Health Care Services rendered to
Covered Persons or claims submitted for
processing under this Benefit Booklet for such
Services. The payment of claims under the
Group Health Plan depends exclusively upon
the funding provided by Monroe County BOCC.
You should read your Benefit Booklet carefully
before you need Health Care Services. It
contains valuable information about:
• your BlueOptions benefits;
• what is covered;
• what is excluded or not covered;
• coverage and payment rules;
• Blueprint for Health Programs;
• how and when to file a claim;
• how much, and under what circumstances,
payment will be made;
• what you will have to pay as your share; and
• 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
When reading your Booklet, please
remember that:
• you should read this Booklet in its entirety in
order to determine if a particular Health Care
Service is covered.
• the headings of sections contained in this
Booklet are for reference purposes only and
shall not affect in any way the meaning or
interpretation of particular provisions.
• references to "you" or "your" throughout refer
to you as the Covered Plan Participant and to
your Covered Dependents, unless expressly
stated otherwise or unless, in the context in
which the term is used, it is clearly intended
otherwise. Any references which refer solely
to you as the Covered Plan Participant or
solely to your Covered Dependent(s) will be
noted as such.
• references to "we ", "us ", and "our" throughout
refer to Blue Cross and Blue Shield of
Florida, Inc. We may also refer to ourselves
as "BCBSF ".
• if a word or phrase starts with a capital letter,
it is either the first word in a sentence, a
proper name, a title, or a defined term. If the
word or phrase has a special meaning, it will
either be defined in the Definitions section or
defined within the particular section where it
is used.
How to Use Your Benefit Booklet 1 -1
Where do you find information on........
• what particular types of Health Care
Services are covered?
Read the "What Is Covered ?" and "What Is
Not Covered ?" sections.
• how much will be paid under your Group
Health Plan and how much do you have to
pay?
Read the "Understanding Your Share of
Health Care Expenses" section along with the
Schedule of Benefits.
• how the amount you pay for Covered
Services under the BlueCard (Out -of-
State) Program will be determined when
you receive care outside the state of
Florida?
• how to add or remove a Dependent?
Read the "Enrollment and Effective Date of
Coverage" section.
• what happens if you are covered under
this Benefit Booklet and another health
plan?
Read the "Duplication of Coverage Under
Other Health Plans Programs" section.
• what happens when your coverage ends?
Read the "Termination of Coverage" section.
• what the terms used throughout this
Booklet mean?
Read the "Definitions" section.
Read the "BlueCard (Out -of- State) Program"
section.
Overview of How BlueOptions Works
Whenever you need care, you have a choice. If you visit an:
In- Network Provider
Out -of- Network Provider
You receive In- Network benefits, the
You receive the Out -of- Network level of
highest level of coverage available.
benefits — you will share more of the cost of
your care.
You do not have to file a claim; the claim
You may be required to submit a claim form.
will be filed by the In- Network Provider for
you.
The In- Network Provider* is responsible
You should notify BCBSF of inpatient
for Admission Notification if you are
admissions.
admitted to the Hospital.
*For Services rendered by an In- Network Provider located outside of Florida, you should
notify us of inpatient admissions.
How to Use Your Benefit Booklet 1 -2
Section 2: What Is Covered?
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This section describes the Health Care Services
that are covered under this Benefit Booklet. All
benefits for Covered Services are subject to
your share of the cost and the benefit
maximums listed on your Schedule of Benefits,
the applicable Allowed Amount, any limitations
and /or exclusions, as well as other provisions
contained in this Booklet, and any
Endorsement(s) in accordance with BCBSF's
Medical Necessity coverage criteria and benefit
guidelines then in effect.
Remember that exclusions and limitations also
apply to your coverage. Exclusions and
limitations that are specific to a type of Service
are included along with the benefit description in
this section. Additional exclusions and
limitations that may apply can be found in the
"What Is Not Covered ?" section. More than one
limitation or exclusion may apply to a specific
Service or a particular situation.
Expenses for the Health Care Services listed in
this section will be covered under this Booklet
only if the Services are:
1. within the Health Care Services categories
in the "What Is Covered ?" section;
2. actually rendered (not just proposed or
recommended) by an appropriately licensed
health care Provider who is recognized for
payment under this Benefit Booklet and for
which an itemized statement or description
of the procedure or Service which was
rendered is received, including any
applicable procedure code, diagnosis code
and other information required in order to
process a claim for the Service;
3. Medically Necessary, as defined in this
Booklet and determined by BCBSF or
BOCC in accordance with BCBSF's Medical
Necessity coverage criteria then in effect,
except as specified in this section;
4. in accordance with the benefit guidelines
listed below;
5. rendered while your coverage is in force;
and
6. not specifically or generally limited or
excluded under this Booklet.
BCBSF or Monroe County BOCC will determine
whether Services are Covered Services under
this Booklet after you have obtained the
Services and a claim has been received for the
Services. In some circumstances BCBSF or
Monroe County BOCC may determine whether
Services might be Covered Services under this
Booklet before you are provided the Service.
For example, BCBSF or Monroe County BOCC
may determine whether a proposed transplant is
a Covered Service under this Booklet before the
transplant is provided. Neither BCBSF nor
Monroe County BOCC are obligated to
determine, in advance, whether any Service not
yet provided to you would be a Covered Service
unless we have specifically designated that a
Service is subject to a prior authorization
requirement as described in the "Blueprint for
Health Programs" section. We are also not
obligated to cover or pay for any Service that
has not actually been rendered to you.
In determining whether Health Care Services
are Covered Services under this Booklet, no
written or verbal representation by any
employee or agent of BCBSF or Monroe County
BOCC, or by any other person, shall waive or
otherwise modify the terms of this Booklet and,
therefore, neither you, nor any health care
Provider or other person should rely on any such
written or verbal representation.
What Is Covered? 2 -1
Our Benefit Guidelines
In providing benefits for Covered Services, the
benefit guidelines listed below apply as well as
any other applicable payment rules specific to
particular categories of Services:
1. Payment for certain Health Care Services is
included within the Allowed Amount for the
primary procedure, and therefore no
additional amount is payable for any such
Services.
2. Payment is based on the Allowed Amount
for the actual Service rendered (i.e.,
payment is not based on the Allowed
Amount for a Service which is more complex
than that actually rendered), and is not
based on the method utilized to perform the
Service or the day of the week or the time of
day the procedure is performed.
3. Payment for a Service includes all
components of the Health Care Service
when the Service can be described by a
single procedure code, or when the Service
is an essential or integral part of the
associated therapeutic /diagnostic Service
rendered.
Covered Services Categories
Accident Care
Health Care Services to treat an injury or illness
resulting from an Accident not related to your job
or employment are covered.
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Health Care Services to treat an injury or illness
resulting from an Accident related to your job or
employment are excluded.
Allergy Testing and Treatments
Testing and desensitization therapy (e.g.,
injections) and the cost of hyposensitization
serum are covered. The Allowed Amount for
allergy testing is based upon the type and
number of tests performed by the Physician.
The Allowed Amount for allergy immunotherapy
treatment is based upon the type and number of
doses.
Ambulance Services
Ambulance Services for Emergency Medical
Conditions and limited non - emergency ground
transport may be covered only when:
1. For Emergency Medical Conditions — it is
Medically Necessary to transport you by air,
ground or water, from the place an
Emergency Medical Condition occurs to the
nearest Hospital that can provide the
Medically Necessary level of care. If it is
determined that the nearest Hospital is
unable to provide the Medically Necessary
level of care for the Emergency Medical
Condition, then coverage forAmbulance
Services shall extend to the next nearest
Hospital that can provide Medically
Necessary care; or
2. For limited non - emergency ground
Ambulance transport — it is Medically
Necessary to transport you by ground:
a. from an Out -of- Network Hospital to the
nearest In- Network Hospital that can
provide care;
b. to the nearest In- Network or Out -of-
Network Hospital for a Condition that
requires a higher level of care that was
not available at the original Hospital;
c. to the nearest more cost - effective acute
care facility as determined solely by us;
or
d. from an acute facility to the nearest
cost - effective sub -acute setting.
Note: Non - emergency Ambulance transportation
meets the definition of Medical Necessity only
when the patient's Condition requires treatment
at another facility and when another mode of
What Is Covered? 2 -2
transportation, (regardless of whether covered
by us or not) would endanger the patient's
medical Condition. If another mode of
transportation could be used safely and
effectively, regardless of time, or mode (e.g. air,
ground, water) then Ambulance transportation is
not Medically Necessary.
Limitations:
AirAmbulance coverage is specifically limited to
transport due to an Emergency Medical
Condition when the patient's destination is an
acute care Hospital, and:
1. the pick -up point is not accessible by ground
Ambulance, or
2. speed in excess of the ground vehicle is
critical for your health or safety.
Air Ambulance transport not due to an
Emergency Medical Condition are excluded
unless specifically authorized by us in
advance of the transport.
Exclusions:
Services for situations that are not Medically
Necessary because they do not require
Ambulance transportation including but not
limited to:
1. Ambulance Services for a patient who is
legally pronounced dead before the
Ambulance is summoned.
2. Aid rendered by an Ambulance crew without
transport. Examples include, but are not
limited to situations when an Ambulance is
dispatched and:
a. the crew renders aid until a helicopter
can be sent;
b. the patient refuses care or transport; or
c. only basic first aid is rendered.
3. Non - emergency transport (not due to an
Emergency Medical Condition) to or from a
patient's home or a residential, domiciliary or
custodial facility.
4. Transfers by medical vans or commercial
transportation (such as Physician owned
limousines, public transportation, cab, etc.).
5. Ambulance transport for patient
convenience or patient and /or family
preference. Examples include but are not
limited to:
a. patient wants to be at a certain Hospital
or facility for personal /preference
reasons;
b. patient is in a foreign country, or out -of-
state, and wants to return home for a
surgical procedure or treatment, or for
continued treatment, including patients
who have recently been discharged
from inpatient care; or
c. patient is going for a routine Service and
is medically able to use another mode of
transportation but can't pay for and /or
find such transportation.
6. Air Ambulance Services in the absence of
an Emergency Medical Condition, unless
such Services are authorized by us in
advance.
Ambulatory Surgical Centers
Health Care Services rendered at an Ambulatory
Surgical Center are covered and include:
1. use of operating and recovery rooms;
2. respiratory, or inhalation therapy (e.g.,
oxygen);
3. drugs and medicines administered (except
for take home drugs) at the Ambulatory
Surgical Center;
4. intravenous solutions;
5. dressings, including ordinary casts;
6. anesthetics and their administration;
What Is Covered? 2 -3
7. administration of, including the cost of,
whole blood or blood products (except as
outlined in the Drugs exclusion of the "What
Is Not Covered ?" section);
8. transfusion supplies and equipment;
9. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG); and
10. chemotherapy treatment for proven
malignant disease.
Anesthesia Administration Services
Administration of anesthesia by a Physician or
Certified Registered Nurse Anesthetist ( "CRNA ")
may be covered. In those instances where the
CRNA is actively directed by a Physician other
than the Physician who performed the surgical
procedure, payment for Covered Services, if
any, will be made for both the CRNA and the
Physician Health Care Services at the lower
directed - services Allowed Amount in accordance
with BCBSF's payment program then in effect
for such Covered Services.
Exclusion:
Coverage does not include anesthesia Services
by an operating Physician, his or her partner or
associate.
Autism Spectrum Disorder
Autism Spectrum Disorder Services provided to
a Covered Dependent who is under the age of
18, or if 18 years of age or older, is attending
high school and was diagnosed with Autism
Spectrum Disorder prior to his or her 9th birthday
consisting of:
well -baby and well -child screening for the
presence of Autism Spectrum Disorder;
2. Applied Behavior Analysis, when rendered
by an individual certified pursuant to Section
393.17 of the Florida Statutes or licensed
under Chapters 490 or 491 of the Florida
Statutes; and
3. Physical Therapy by a Physical Therapist,
Occupational Therapy by an Occupational
Therapist, and Speech Therapy by a
Speech Therapist. Covered therapies
provided in the treatment of Autism
Spectrum Disorder are covered even though
they may be habilitative in nature (provided
to teach a function) and are not necessarily
limited to restoration of a function or skill that
has been lost.
Payment Guidelines for Autism Spectrum
Disorder
Applied Behavior Analysis Services for Autism
Spectrum Disorder must be authorized in
accordance with criteria established by us,
before such Services are rendered. Services
performed without authorization will be denied.
Authorization for coverage is not required when
Covered Services are provided for the treatment
of an Emergency Medical Condition.
Exclusion:
Any Services for the treatment of Autism
Spectrum Disorder other than as specifically
identified as covered in this section.
Note: In order to determine whether such
Services are covered under this Benefit Booklet,
we reserve the right to request a formal written
treatment plan signed by the treating physician
to include the diagnosis, the proposed treatment
type, the frequency and duration of treatment,
the anticipated outcomes stated as goals, and
the frequency with which the treatment plan will
be updated, but no less than every 6 months.
This benefit booklet will only cover services to
the extent included in the Treating Physician's
formal written treatment plan.
Behavioral Health Services
Mental Health Services
Diagnostic evaluation, psychiatric treatment,
individual therapy, and group therapy rendered
to you by a Physician, Psychologist or Mental
Health Professional for the treatment of a Mental
What Is Covered? 2-4
and Nervous Disorder may be covered.
Covered Services may include:
1. Physician office visits;
2. Intensive Outpatient Treatment (rendered in
a facility), as defined in this Booklet;
3. Partial Hospitalization, as defined in this
Booklet, when provided under the direction
of a Physician; and
4. Residential Treatment Services, as defined
in this Booklet.
Exclusion:
1. Services rendered for a Condition that is not
a Mental and Nervous Disorder as defined in
this Booklet, regardless of the underlying
cause, or effect, of the disorder;
2. Services for psychological testing
associated with the evaluation and diagnosis
of learning disabilities or intellectual
disability;
3. Services beyond the period necessary for
evaluation and diagnosis of learning
disabilities or intellectual disability;
4. Services for educational purposes;
5. Services for marriage counseling unless
related to a Mental and Nervous Disorder as
defined in this Booklet, regardless of the
underlying cause, or effect, of the disorder;
6. Services for pre - marital counseling;
7. Services for court- ordered care or testing, or
required as a condition of parole or
probation;
8. Services to test aptitude, ability, intelligence
or interest [except as covered under the
Autism Spectrum Disorder subsection];
9. Services required to maintain employment;
10. Services for cognitive remediation; and
11. inpatient stays that are primarily intended as
a change of environment.
Substance Deoendencv Treatment Services
When there is a sudden drop in consumption
after prolonged heavy use of a substance a
person may experience withdrawal, often
causing both physiologic and cognitive
symptoms. The symptoms of withdrawal vary
greatly, ranging from minimal changes to
potentially life threatening states. Detoxification
Services can be rendered in different types of
locations, depending on the severity of the
withdrawal symptoms.
Care and treatment for Substance Dependency
includes the following:
1. Inpatient and outpatient Health Care
Services rendered by a Physician,
Psychologist or Mental Health Professional
in a program accredited by The Joint
Commission or approved by the state of
Florida for Detoxification or Substance
Dependency.
2. Physician, Psychologist and Mental Health
Professional outpatient visits for the care
and treatment of Substance Dependency.
We may provide you with information on
resources available to you for non - medical
ancillary services like vocational rehabilitation or
employment counseling, when we are able to.
We don't pay for any services that are provided
to you by any of these resources; they are to be
provided solely at your expense. You
acknowledge that we do not have any
Contractual or other formal arrangements with
the Provider of such services.
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Long term Services for alcoholism or drug
addiction, including specialized inpatient units or
inpatient stays that are primarily intended as a
change of environment.
Breast Reconstructive Surgery
Surgery to reestablish symmetry between two
breasts and implanted prostheses incident to
What Is Covered? 2 -5
Mastectomy is covered. In order to be covered,
such surgery must be provided in a manner
chosen by your Physician, consistent with
prevailing medical standards, and in consultation
with you.
Child Cleft Lip and Cleft Palate Treatment
Treatment and Services for Child Cleft Lip and
Cleft Palate, including medical, dental, Speech
Therapy, audiology, and nutrition Services for
treatment of a child under the age of 18 who has
cleft lip or cleft palate are covered. In order for
such Services to be covered, your Covered
Dependent's Physician must specifically
prescribe such Services and such Services must
be Medically Necessary and consequent to
treatment of the cleft lip or cleft palate.
Clinical Trials
Clinical trials are research studies in which
Physicians and other researchers work to find
ways to improve care. Each study tries to
answer scientific questions and to find better
ways to prevent, diagnose, or treat patients.
Each trial has a protocol which explains the
purpose of the trial, how the trial will be
performed, who may participate in the trial, and
the beginning and end points of the trial.
If you are eligible to participate in an Approved
Clinical Trial, routine patient care for Services
furnished in connection with your participation in
the Approved Clinical Trial may be covered
when:
1. an In- Network Provider has indicated such
trial is appropriate for you; or
2. you provide us with medical and scientific
information establishing that your
participation in such trial is appropriate.
Routine patient care includes all Medically
Necessary Services that would otherwise be
covered under this Booklet, such as doctor
visits, lab tests, x -rays and scans and hospital
stays related to treatment of your Condition and
is subject to the applicable Cost Share(s) on the
Schedule of Benefits.
Even though benefits may be available under
this Booklet for routine patient care related to an
Approved Clinical Trial you may not be eligible
for inclusion in these trials or there may not be
any trials available to treat your Condition at the
time you want to be included in a clinical trial.
Exclusion:
1. Costs that are generally covered by the
clinical trial, including, but not limited to
a. Research costs related to conducting
the clinical trial such as research
Physician and nurse time, analysis of
results, and clinical tests performed only
for research purposes.
b. The investigational item, device or
Service itself.
c. Services inconsistent with widely
accepted and established standards of
care for a particular diagnosis.
2. Services related to an Approved Clinical
Trial received outside of the United States
Concurrent Physician Care
Concurrent Physician care Services are
covered, provided: (a) the additional Physician
actively participates in your treatment; (b) the
Condition involves more than one body system
or is so severe or complex that one Physician
cannot provide the care unassisted; and (c) the
Physicians have different specialties or have the
same specialty with different sub - specialties.
Consultations
Consultations provided by a Physician are
covered if your attending Physician requests the
consultation and the consulting Physician
prepares a written report.
Contraceptive Injections
What Is Covered? 2 -6
Medication by injection is covered when
provided and administered by a Physician, for
the purpose of contraception, and is limited to
the medication and administration when
Medically Necessary.
1. Dental Services provided more than 90 days
after the date of an Accidental Dental Injury
regardless of whether or not such services
could have been rendered within 90 days;
and
Dental Services
2. Dental Implant.
Dental Services are limited to the following:
Diabetes Outpatient Self- Management
1. Care and stabilization treatment rendered
Diabetes outpatient self- management training
within 90 days of an Accidental Dental Injury
and educational Services and nutrition
to Sound Natural Teeth.
counseling (including all Medically Necessary
2. Extraction of teeth required prior to radiation
equipment and supplies) to treat diabetes, if
therapy when you have a diagnosis of
your treating Physician or a Physician who
cancer of the head and /or neck.
specializes in the treatment of diabetes certifies
3. Anesthesia Services for dental care
that such Services are Medically Necessary, are
including general anesthesia and
covered. In order to be covered, diabetes
hospitalization Services necessary to assure
outpatient self- management training and
the safe delivery of necessary dental care
educational Services must be provided under
provided to you or your Covered Dependent
the direct supervision of a certified Diabetes
in a Hospital or Ambulatory Surgical Center
Educator or a board - certified Physician
if:
specializing in endocrinology. Additionally, in
order to be covered, nutrition counseling must
a) the Covered Dependent is under 8
be provided by a licensed Dietitian. Covered
years of age and it is determined by a
Services may also include the trimming of
dentist and the Covered Dependent's
toenails, corns, calluses, and therapeutic shoes
Physician that:
(including inserts and /or modifications) for the
i. dental treatment is necessary due to
treatment of severe diabetic foot disease.
a dental Condition that is
Diagnostic Services
significantly complex; or
Diagnostic Services when ordered by a
ii. the Covered Dependent has a
Physician are limited to the following:
developmental disability in which
patient management in the dental
1. radiology, ultrasound and nuclear medicine,
office has proven to be ineffective;
Magnetic Resonance Imaging (MRI);
or
2. laboratory and pathology Services;
b) you or your Covered Dependent has
3. Services involving bones or joints of the jaw
one or more medical Conditions that
(e.g., Services to treat temporomandibular
would create significant or undue
joint [TMJ] dysfunction) or facial region if,
medical risk for you in the course of
under accepted medical standards, such
delivery of any necessary dental
diagnostic Services are necessary to treat
treatment or surgery if not rendered in a
Conditions caused by congenital or
Hospital or Ambulatory Surgical Center.
developmental deformity, disease, or injury;
Exclusion:
4. approved machine testing (e.g.,
electrocardiogram [EKG],
electroencephalograph [EEG], and other
What Is Covered? 2 -7
electronic diagnostic medical procedures);
and
5. genetic testing for the purposes of
explaining current signs and symptoms of a
possible hereditary disease.
Dialysis Services
Dialysis Services including equipment, training,
and medical supplies, when provided at any
location by a Provider licensed to perform
dialysis including a Dialysis Center are covered
Down Syndrome
Down syndrome Services provided to a Covered
Dependent who is under the age of 18, or if 18
years of age or older is attending high school,
consisting of:
1. Applied Behavior Analysis, when rendered
by an individual certified per Section 393.17
of the Florida Statutes; and
2. Physical Therapy by a Physical Therapist,
Occupational Therapy by an Occupational
Therapist, and Speech Therapy by a
Speech Therapist. Covered therapies
provided in the treatment of Down syndrome
are covered even though they may be
habilitative in nature (provided to teach a
function) and are not necessarily limited to
restoration of a function or skill that has
been lost.
Payment Guidelines for Down Syndrome
Applied Behavior Analysis Services for Down
syndrome must be authorized in accordance
with criteria established by us, before such
Services are rendered. Services performed
without authorization will be denied.
Authorization for coverage is not required for
Emergency Services provided for the treatment
of an Emergency Medical Condition.
Note: In order to determine whether such
Services are covered under this Booklet, we
reserve the right to request a formal written
treatment plan signed by the treating Physician
to include the diagnosis, the proposed treatment
type, the frequency and duration of treatment,
the anticipated outcomes stated as goals, and
the frequency with which the treatment plan will
be updated, but no less than every 6 months.
Durable Medical Equipment
Durable Medical Equipment when provided by a
Durable Medical Equipment Provider and when
prescribed by a Physician, limited to the most
cost - effective equipment as determined by
BCBSF or Monroe County BOCC is covered.
Payment Guidelines for Durable Medical
Equipment
Supplies and service to repair medical
equipment may be Covered Services only if you
own the equipment or you are purchasing the
equipment. Payment for Durable Medical
Equipment will be based on the lowest of the
following: 1) the purchase price; 2) the
lease /purchase price; 3) the rental rate; or 4) the
Allowed Amount. The Allowed Amount for such
rental equipment will not exceed the total
purchase price. Durable Medical Equipment
includes, but is not limited to, the following:
wheelchairs, crutches, canes, walkers, hospital
beds, and oxygen equipment.
Note: Repair or replacement of Durable
Medical Equipment due to growth of a child or
significant change in functional status is a
Covered Service.
Exclusion:
Equipment which is primarily for convenience
and /or comfort; modifications to motor vehicles
and /or homes, including but not limited to,
wheelchair lifts or ramps; water therapy devices
such as Jacuzzis, hot tubs, swimming pools or
whirlpools; exercise and massage equipment,
electric scooters, hearing aids, air conditioners
and purifiers, humidifiers, water softeners and /or
purifiers, pillows, mattresses or waterbeds,
escalators, elevators, stair glides, emergency
alert equipment, handrails and grab bars, heat
What Is Covered? 2 -8
appliances, dehumidifiers, and the replacement
of Durable Medical Equipment solely because it
is old or used are excluded.
Emergency Services
Emergency Services for an Emergency Medical
Condition are covered when rendered In-
Network and Out -of- Network without the need
for any prior authorization determination by us.
When Emergency Services and care for an
Emergency Medical Condition are rendered by
an Out -of- Network Provider, any Copayment
and /or Coinsurance amount applicable to In-
Network Providers for Emergency Services will
also apply to such Out -of- Network Provider.
Special Payment Rules for Non - Grandfathered
Plans
The Patient Protection and Affordable Care Act
(PPACA) requires that non - grandfathered health
plans apply a specific method for determining
the allowed amount for Emergency Services
rendered for an Emergency Medical Condition
by Providers who do not have a contract with us
Payment for Emergency Services rendered by
an Out -of- Network Provider that has not entered
into an agreement with BCBSF to provide
access to a discount from the billed amount of
that Provider will be the greater of:
1. the amount equal to the median amount
negotiated with all BCBSF In- Network
Providers for the same Services;
2. the Allowed Amount as defined in the
Booklet; or
3. what Medicare would have paid for the
Services rendered.
In no event will Out -of- Network Providers be
paid more than their charges for the Services
rendered.
Enteral Formulas
Prescription and non - prescription enteral
formulas for home use when prescribed by a
Physician as necessary to treat inherited
diseases of amino acid, organic acid,
carbohydrate or fat metabolism as well as
malabsorption originating from congenital
defects present at birth or acquired during the
neonatal period are covered.
Coverage to treat inherited diseases of amino
acid and organic acids, for you up to your 25th
birthday, shall include coverage for food
products modified to be low protein.
Eye Care
Coverage includes the following Services:
1. Physician Services, soft lenses or sclera
shells, for the treatment of aphakic patients;
2. initial glasses or contact lenses following
cataract surgery; and
3. Physician Services to treat an injury to or
disease of the eyes.
Exclusion:
Health Care Services to diagnose or treat vision
problems which are not a direct consequence of
trauma or prior ophthalmic surgery; eye
examinations; eye exercises or visual training;
eye glasses and contact lenses and their fitting
are excluded. In addition to the above, any
surgical procedure performed primarily to correct
or improve myopia or other refractive disorders
(e.g., radial keratotomy, PRK and LASIK) are
excluded.
Home Health Care
The Home Health Care Services listed below
are covered when the following criteria are met:
1. you are unable to leave your home without
considerable effort and the assistance of
another person because you are: bedridden
or chairbound or because you are restricted
in ambulation whether or not you use
assistive devices; or you are significantly
limited in physical activities due to a
Condition; and
What Is Covered? 2 -9
2. the Home Health Care Services rendered
have been prescribed by a Physician by way
of a formal written treatment plan that has
been reviewed and renewed by the
prescribing Physician every 30 days. In
order to determine whether such Services
are covered under this Booklet, you may be
required to provide a copy of any written
treatment plan;
3. the Home Health Care Services are
provided directly by (or indirectly through) a
Home Health Agency; and
4. you are meeting or achieving the desired
treatment goals set forth in the treatment
plan as documented in the clinical progress
notes.
Home Health Care Services are limited to:
part -time (i.e., less than 8 hours per day and
less than a total of 40 hours in a calendar
week) or intermittent (i.e., a visit of up to, but
not exceeding, 2 hours per day) nursing
care by a Registered Nurse, Licensed
Practical Nurse and /or home health aide
Services;
2. home health aide Services must be
consistent with the plan of treatment,
ordered by a Physician, and rendered under
the supervision of a Registered Nurse;
3. medical social services;
4. nutritional guidance;
5. respiratory, or inhalation therapy (e.g.,
oxygen); and
6. Physical Therapy by a Physical Therapist,
Occupational Therapy by a Occupational
Therapist, and Speech Therapy by a
Speech Therapist.
Exclusions:
1. homemaker or domestic maid services;
2. sitter or companion services;
3. Services rendered by an employee or
operator of an adult congregate living
facility; an adult foster home; an adult day
care center, or a nursing home facility;
4. Speech Therapy provided for a diagnosis of
developmental delay;
5. Custodial Care except for any such care
covered under this subsection when
provided on a part -time or intermittent basis
(as defined above) by a home health aide;
6. food, housing, and home delivered meals;
and
7. Services rendered in a Hospital, nursing
home, or intermediate care facility.
Hospice Services
Health Care Services provided in connection
with a Hospice treatment program may be
Covered Services, provided the Hospice
treatment program is:
1. approved by your Physician; and
2. your doctor has certified to us in writing that
your life expectancy is 12 months or less.
Recertification is required every six months
Hospital Services
Covered Hospital Services include:
1. room and board in a semi - private room
when confined as an inpatient, unless the
patient must be isolated from others for
documented clinical reasons;
2. intensive care units, including cardiac,
progressive and neonatal care;
3. use of operating and recovery rooms;
4. use of emergency rooms;
5. respiratory, pulmonary, or inhalation therapy
(e.g., oxygen);
6. drugs and medicines administered (except
for take home drugs) by the Hospital;
7. intravenous solutions;
What Is Covered? 2 -10
8. administration of, including the cost of,
whole blood or blood products except as
outlined in the Drugs exclusion of the "What
Is Not Covered ?" section);
9. dressings, including ordinary casts;
10. anesthetics and their administration;
11. transfusion supplies and equipment;
12. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG);
13. Physical, Speech, Occupational, and
Cardiac Therapies; and
14. transplants as described in the Transplant
Services subsection.
Exclusion:
Expenses for the following Hospital Services are
excluded when such Services could have been
provided without admitting you to the Hospital:
1) room and board provided during the
admission; 2) Physician visits provided while you
were an inpatient; 3) Occupational Therapy,
Speech Therapy, Physical Therapy, and Cardiac
Therapy; and 4) other Services provided while
you were an inpatient.
In addition, expenses for the following and
similar items are also excluded:
1. gowns and slippers;
2. shampoo, toothpaste, body lotions and
hygiene packets;
3. take -home drugs;
4. telephone and television;
5. guest meals or gourmet menus; and
6. admission kits.
Inpatient Rehabilitation
Inpatient Rehabilitation Services are covered
when the following criteria are met:
1. Services must be provided under the
direction of a Physician and must be
provided by a Medicare certified facility in
accordance with a comprehensive
rehabilitation program;
2. a plan of care must be developed and
managed by a coordinated multi - disciplinary
team;
3. coverage is subject to our Medical Necessity
coverage criteria then in effect;
4. the individual must be able to actively
participate in at least 2 rehabilitative
therapies and be able to tolerate at least 3
hours per day of skilled Rehabilitation
Services for at least 5 days a week and their
Condition must be likely to result in
significant improvement; and
5. the Rehabilitation Services must be required
at such intensity, frequency and duration
that further progress cannot be achieved in
a less intensive setting.
Inpatient Rehabilitation Services are subject to
the inpatient facility Copayment, if applicable,
and the benefit maximum set forth in the
Schedule of Benefits.
Exclusion:
All Substance Dependency, drug and alcohol
related diagnoses, Pain Management, and
respiratory ventilator management Services are
excluded.
Mammograms
Mammograms obtained in a medical office,
medical treatment facility or through a health
testing service that uses radiological equipment
registered with the appropriate Florida regulatory
agencies (or those of another state) for
diagnostic purposes or breast cancer screening
are Covered Services.
Benefits for mammograms may not be subject to
the Deductible, Coinsurance, or Copayment (if
What Is Covered? 2 -11
applicable). Please refer to your Schedule of
Benefits for more information.
Mastectomy Services
Breast cancer treatment including treatment for
physical complications relating to a Mastectomy
(including lymphedemas), and outpatient post-
surgical follow -up in accordance with prevailing
medical standards as determined by you and
your attending Physician are covered.
Outpatient post - surgical follow -up care for
Mastectomy Services shall be covered when
provided by a Provider in accordance with the
prevailing medical standards and at the most
medically appropriate setting. The setting may
be the Hospital, Physician's office, outpatient
center, or your home. The treating Physician,
after consultation with you, may choose the
appropriate setting.
Maternity Services
Health Care Services, including prenatal care,
delivery and postpartum care and assessment,
provided to you, by a Doctor of Medicine (M.D.),
Doctor of Osteopathy (D.O.), Hospital, Birth
Center, Midwife or Certified Nurse Midwife may
be Covered Services. Care for the mother
includes the postpartum assessment.
In order for the postpartum assessment to be
covered, such assessment must be provided at
a Hospital, an attending Physician's office, an
outpatient maternity center, or in the home by a
qualified licensed health care professional
trained in care for a mother. Coverage under
this Booklet for the postpartum assessment
includes coverage for the physical assessment
of the mother and any necessary clinical tests in
keeping with prevailing medical standards.
Under Federal law, your Group Plan generally
may not restrict benefits for any hospital length
of stay in connection with childbirth for the
mother or newborn child to less than 48 hours
following a vaginal delivery; or less than 96
hours following a cesarean section. However,
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
provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours (or
96 hours).
Exclusion:
Maternity Services rendered to a Covered
Person who becomes pregnant as a Gestational
Surrogate under the terms of, and in accordance
with, a Gestational Surrogacy Contract or
Arrangement are excluded. This exclusion
applies to all expenses for prenatal, intra - partal,
and post - partal Maternity /Obstetrical Care, and
Health Care Services rendered to the Covered
Person acting as a Gestational Surrogate.
For the definition of Gestational Surrogate and
Gestational Surrogacy Contract, see the
"Definitions" section of this Benefit Booklet.
Medical Pharmacy
Physician- administered Prescription Drugs
which are rendered in a Physician's office may
be subject to a separate Cost Share amount that
is in addition to the office visit Cost Share
amount. The Medical Pharmacy Cost Share
amount applies to each Prescription Drug and
does not include the administration of the
Prescription Drug.
Your plan may also include a maximum monthly
amount you will be required to pay out -of- pocket
for Medical Pharmacy, when such Services are
provided by an In- Network Provider or Specialty
Pharmacy. If your plan includes a Medical
Pharmacy out -of- pocket monthly maximum, it
will be listed on your Schedule of Benefits and
only applies after you have met your Deductible,
if applicable.
Please refer to your Schedule of Benefits for the
additional Cost Share amount and /or monthly
What Is Covered? 2 -12
maximum out -of- pocket applicable to Medical
Pharmacy for your plan.
Note: For purposes of this benefit, allergy
injections and immunizations are not considered
Medical Pharmacy.
Newborn Care
A newborn child will be covered from the
moment of birth provided that the newborn child
is eligible for coverage and properly enrolled.
Covered Services shall consist of coverage for
injury or sickness, including the necessary care
or treatment of medically diagnosed congenital
defects, birth abnormalities, and premature birth.
Newborn Assessment
An assessment of the newborn child is covered
provided the Services were rendered at a
Hospital, the attending Physician's office, a Birth
Center, or in the home by a Physician, Midwife
or Certified Nurse Midwife, and the performance
of any necessary clinical tests and
immunizations are within prevailing medical
standards. These Services are not subject to
the Deductible.
Ambulance Services, when necessary to
transport the newborn child to and from the
nearest appropriate facility which is staffed and
equipped to treat the newborn child's Condition,
as determined by BCBSF or Monroe County
BOCC and certified by the attending Physician
as Medically Necessary to protect the health and
safety of the newborn child, are covered.
Under Federal law, your Group Plan generally
may not restrict benefits for any hospital length
of stay in connection with childbirth for the
mother or newborn child to less than 48 hours
following a vaginal delivery; or less than 96
hours following a cesarean section. However,
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
provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours (or
96 hours).
Orthotic Devices
Orthotic Devices including braces and trusses
for the leg, arm, neck and back, and special
surgical corsets are covered when prescribed by
a Physician and designed and fitted by an
Orthotist.
Benefits may be provided for necessary
replacement of an Orthotic Device which is
owned by you when due to irreparable damage,
wear, a change in your Condition, or when
necessitated due to growth of a child.
Payment for splints for the treatment of
temporomandibular joint ( "TMJ") dysfunction is
limited to payment for one splint in a six -month
period unless a more frequent replacement is
determined by BCBSF or Monroe County BOCC
to be Medically Necessary.
Exclusion:
1. Expenses for arch supports, shoe inserts
designed to effect conformational changes
in the foot or foot alignment, orthopedic
shoes, over - the - counter, custom -made or
built -up shoes, cast shoes, sneakers, ready -
made compression hose or support hose, or
similar type devices /appliances regardless
of intended use, except for therapeutic
shoes (including 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
What Is Covered? 2 -13
alternative to an internal fixation device as a
result of surgery for craniosynostosis; and
3. Expenses for devices necessary to exercise,
train, or participate in sports, e.g. custom -
made knee braces.
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
glucocorticoid (steroid) therapy; or
4. individuals who have primary
hyperparathyroidism; or
5. Individuals who have a family history of
osteoporosis.
Outpatient Cardiac, Occupational, Physical,
Speech, Massage Therapies and Spinal
Manipulation Services
Outpatient therapies listed below may be
Covered Services when ordered by a Physician
or other health care professional licensed to
perform such Services. The outpatient therapies
listed in this category are in addition to the
Cardiac, Occupational, Physical and Speech
Therapy benefits listed in the Home Health
Care, Hospital, and Skilled Nursing Facility
categories herein.
Cardiac Therapy Services provided under the
supervision of a Physician, or an appropriate
Provider trained for Cardiac Therapy, for the
purpose of aiding in the restoration of normal
heart function in connection with a myocardial
infarction, coronary occlusion or coronary
bypass surgery are covered.
Occupational Therapy Services provided by a
Physician or Occupational Therapist for the
purpose of aiding in the restoration of a
previously impaired function lost due to a
Condition are covered.
Speech Therapy Services of a Physician,
Speech Therapist, or licensed audiologist to aid
in the restoration of speech loss or an
impairment of speech resulting from a Condition
are covered.
Physical Therapy Services provided by a
Physician or Physical Therapist for the purpose
of aiding in the restoration of normal physical
function lost due to a Condition are covered.
Massage Therapy Massage provided by a
Physician, Massage Therapist, or Physical
Therapist when the Massage is prescribed as
being Medically Necessary by a Physician
licensed pursuant to Florida Statutes Chapter
458 (Medical Practice), Chapter 459
(Osteopathy), Chapter 460 (Chiropractic) or
Chapter 461 (Podiatry) is covered. The
Physician's prescription must specify the
number of treatments.
Payment Guidelines for Massage and
Physical Therapy
1. Payment for covered Massage Services is
limited to no more than four (4) 15- minute
Massage treatments per day, not to exceed
the Outpatient Cardiac, Occupational,
Physical, Speech, and Massage Therapies
and Spinal Manipulations benefit maximum
listed on the Schedule of Benefits.
2. Payment for a combination of covered
Massage and Physical Therapy Services
rendered on the same day is limited to no
more than four (4) 15- minute treatments per
day for combined Massage and Physical
Therapy treatment, not to exceed the
Outpatient Cardiac, Occupational, Physical,
Speech, and Massage Therapies and Spinal
What Is Covered? 2 -14
Manipulations benefit maximum listed on the
Schedule of Benefits.
3. Payment for covered Physical Therapy
Services rendered on the same day as
spinal manipulation is limited to one (1)
Physical Therapy treatment per day not to
exceed fifteen (15) minutes in length.
Spinal Manipulations: Services by Physicians
for manipulations of the spine to correct a slight
dislocation of a bone or joint that is
demonstrated by x -ray are covered.
Payment Guidelines for Spinal Manipulation
1. Payment for covered spinal manipulation is
limited to no more than 26 spinal
manipulations per Benefit Period, or the
maximum benefit listed in the Schedule of
Benefits, whichever occurs first.
2. Payment for covered Physical Therapy
Services rendered on the same day as a
spinal manipulation is limited to one (1)
Physical Therapy treatment per day, not to
exceed fifteen (15) minutes in length.
Your Schedule of Benefits sets forth the
maximum number of visits covered under this
plan for any combination of the outpatient
therapies and spinal manipulation Services
listed above. For example, even if you may
have only been administered two (2) of the
spinal manipulations for the Benefit Period, any
additional spinal manipulations for that Benefit
Period will not be covered if you have already
met the combined therapy visit maximum with
other Services.
Oxygen
Expenses for oxygen, the equipment necessary
to administer it, and the administration of oxygen
are covered.
Physician Services
Medical or surgical Health Care Services
provided by a Physician, including Services
rendered in the Physician's office, in an
outpatient facility, or electronically through a
computer via the Internet.
Payment Guidelines for Physician Services
Provided by Electronic Means through a
Computer:
Expenses for online medical Services provided
electronically through a computer by a Physician
via the Internet will be covered only if such
Services:
1. were provided to a covered individual who
was, at the time the Services were provided,
an established patient of the Physician
rendering the Services;
2. were in response to an online inquiry
received through the Internet from the
covered individual with respect to which the
Services were provided; and
3. were provided by a Physician through a
secure online healthcare communication
services vendor that, at the time the
Services were rendered, was under contract
with BCBSF.
The term "established patient," as used herein,
shall mean that the covered individual has
received professional services from the
Physician who provided the online medical
Services, or another physician of the same
specialty who belongs to the same group
practice as that Physician, within the past three
years.
Exclusion:
Expenses for online medical Services provided
electronically through a computer by a Physician
via the Internet other than through a healthcare
communication services vendor that has entered
into contract with BCBSF are excluded.
Expenses for online medical Services provided
by a health care provider that is not a Physician
and expenses for Health Care Services
rendered by telephone (except as indicated as
covered under the Preventive Health Services
What Is Covered? 2 -15
category of the WHAT IS COVERED? section)
are also excluded.
Preventive Health Services
Preventive Services are covered for both adults
and children based on prevailing medical
standards and recommendations which are
explained further below. Some examples of
preventive health Services include, but are not
limited to, periodic routine health exams, routine
gynecological exams, immunizations and related
preventive Services such as Prostate Specific
Antigen (PSA), routine mammograms and pap
smears. In order to be covered, Services shall
be provided in accordance with prevailing
medical standards consistent with:
1. evidence -based items or Services that have
in effect a rating of `A' or `B' in the current
recommendations of the U.S. Preventive
Services Task Force established under the
Public Health Service Act;
2. immunizations that have in effect a
recommendation from the Advisory
Committee on Immunization Practices of the
Centers for Disease Control and Prevention
established under the Public Health Service
Act with respect to the individual involved;
3. with respect to infants, children, and
adolescents, evidence- informed preventive
care and screenings provided for in the
comprehensive guidelines supported by the
Health Resources and Services
Administration; and
4. with respect to women, such additional
preventive care and screenings not
described in paragraph number one as
provided for in comprehensive guidelines
supported by the Health Resources and
Services Administration.
More detailed information, such as medical
management programs or limitations, on
Services that are covered under the Preventive
Health Services category is available in the
Preventive Services Guide located on our
website at
www. FloridaBlue .com /heaIthresources Drugs
or Supplies covered as Preventive Services are
described in the Medication Guide. In order to
be covered as a Preventive Health Service
under this section the Service must be provided
as described in the Preventive Services Guide
or, for Drugs and Supplies, in the Medication
Guide.
Note: From time to time medical standards that
are based on the recommendations of the
entities listed in numbers 1 through 4 above
change. Services may be added to the
recommendations and sometimes may be
removed. It is important to understand that your
coverage for these preventive Services is based
on what is in effect on your Effective Date. If
any of the recommendations or guidelines
change after your Effective Date, your coverage
will not change until your Group's first
Anniversary Date one year after the
recommendations or guidelines go into effect.
For example, if the USPSTF adds a new
recommendation for a preventive Service that
we do not cover and you are already covered
under this Benefit Booklet; that new Service will
not be a Covered Service under this category
right away. The coverage for a new Service will
start on your Group's Anniversary Date one year
after the new recommendation goes into effect.
Exclusion:
Routine vision and hearing examinations and
screenings are not covered, except as required
under paragraph one above.
Prosthetic Devices
The following Prosthetic Devices are covered
when prescribed by a Physician and designed
and fitted by a Prosthetist:
1. artificial hands, arms, feet, legs and eyes,
including permanent implanted lenses
What Is Covered? 2 -16
following cataract surgery, cardiac
pacemakers, and prosthetic devices incident
to a Mastectomy;
2. appliances needed to effectively use artificial
limbs or corrective braces; or
3. penile prosthesis.
Covered Prosthetic Devices (except cardiac
pacemakers, and Prosthetic Devices incident to
Mastectomy) are limited to the first such
permanent prosthesis (including the first
temporary prosthesis if it is determined to be
necessary) prescribed for each specific
Condition.
Benefits may be provided for necessary
replacement of a Prosthetic Device which is
owned by you when due to irreparable damage,
wear, or a change in your Condition, or when
necessitated due to growth of a child.
Exclusion:
1. Expenses for microprocessor controlled or
myoelectric artificial limbs (e.g. C- legs); and
2. Expenses for cosmetic enhancements to
artificial limbs.
Self- Administered Prescription Drugs
The following Self- Administered Drugs are
covered:
Self- Administered Prescription Drugs used
in the treatment of diabetes, cancer,
Conditions requiring immediate stabilization
(e.g. anaphylaxis), or in the administration of
dialysis; and
2. Specialty Drugs used to increase height or
bone growth (e.g., growth hormone), must
meet the following criteria in order to be
covered:
a. Must be prescribed for Conditions of
growth hormone deficiency documented
with two abnormally low stimulation
tests of less than 10 ng /ml and one
abnormally low growth hormone
dependent peptide or for Conditions of
growth hormone deficiency associated
with loss of pituitary function due to
trauma, surgery, tumors, radiation or
disease, or for state mandated use as in
patients with AIDS.
b. Continuation of growth hormone therapy
is only covered for Conditions
associated with significant growth
hormone deficiency when there is
evidence of continued responsiveness
to treatment. Treatment is considered
responsive in children less than 21
years of age, when the growth hormone
dependent peptide (IGF -1) is in the
normal range for age and Tanner
development stage; the growth velocity
is at least 2 cm per year, and studies
demonstrate open epiphyses.
Treatment is considered responsive in
both adolescents with closed epiphyses
and for adults, who continue to evidence
growth hormone deficiency and the IGF-
1 remains in the normal range for age
and gender.
Skilled Nursing Facilities
The following Health Care Services may be
Covered Services when you are an inpatient in a
Skilled Nursing Facility:
1. room and board;
2. respiratory, pulmonary, or inhalation therapy
(e.g., oxygen);
3. drugs and medicines administered while an
inpatient (except take home drugs);
4. intravenous solutions;
5. administration of, including the cost of,
whole blood or blood products(except as
outlined in the Drugs exclusion of the "What
Is Not Covered ?" section);
6. dressings, including ordinary casts;
What Is Covered? 2 -17
7. transfusion supplies and equipment;
8. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG);
9. chemotherapy treatment for proven
malignant disease; and
10. Physical, Speech, and Occupational
Therapies;
A treatment plan from your Physician may be
required in order to determine coverage and
payment.
Exclusion:
Expenses for an inpatient admission to a Skilled
Nursing Facility for purposes of Custodial Care,
convalescent care, or any other Service
primarily for the convenience of you and /or your
family members or the Provider are excluded.
Surgical Assistant Services
Services rendered by a Physician, Registered
Nurse First Assistant or Physician Assistant
when acting as a surgical assistant (provided no
intern, resident, or other staff physician is
available) when the assistant is necessary are
covered.
Surgical Procedures
Surgical procedures performed by a Physician
may be covered including the following:
sterilization (tubal ligations and
vasectomies), regardless of Medical
Necessity;
2. surgery to correct deformity which was
caused by disease, trauma, birth defects,
growth defects or prior therapeutic
processes;
3. oral surgical procedures for excisions of
tumors, cysts, abscesses, and lesions of the
mouth;
4. surgical procedures involving bones orjoints
of the jaw (e.g., temporomandibular joint
[TMJ]) and facial region if, under accepted
medical standards, such surgery is
necessary to treat Conditions caused by
congenital or developmental deformity,
disease, or injury;
5. Services of a Physician for the purpose of
rendering a second surgical opinion and
related diagnostic services to help determine
the need for surgery.
Exclusions:
The following Services, which are
considered cosmetic in nature, are not
covered when used to improve the gender -
specific appearance of an individual.
Examples of Services which are considered
cosmetic include, but are not limited to:
a. reduction thyroid chondroplasty;
b. liposuction;
c. rhinoplasty;
d. facial bone reconstruction;
e. face lift;
f. blepharoplasty;
g. voice modification surgery;
h. hair removal /hairplasty; or
i. breast augmentation.
7. Surgical procedures performed on a Covered
Plan Participant for the treatment of Morbid
Obesity (e.g., intestinal bypass, stomach
stapling, balloon dilation) and the associated
care provided the Covered Plan Participant
has not previously undergone the same or
similar procedure in the lifetime of this
Group Health Plan when medically
necessary.
Exclusion:
What Is Covered? 2 -18
a. Surgical procedures for the treatment of
Morbid Obesity including: intestinal
bypass; stomach stapling; balloon
dilation and associated care for the
surgical treatment of Morbid Obesity, if
the Covered Plan Participant has
previously undergone the same or
similar procedures in the lifetime of this
Group Health Plan. Surgical procedures
performed to revise, or correct defects
related to, a prior intestinal bypass,
stomach stapling or balloon dilation are
also excluded.
b. Reversal of a weight loss surgery,
surgical procedures to revise, correct,
and correction of defects to include
adjustment to devices implanted or any
fills not performed during the initial
surgical event.
Payment Guidelines for Surgical Procedures
Payment for multiple surgical procedures
performed in addition to the primary surgical
procedure, on the same or different areas of
the body, during the same operative session
will be based on 50 percent of the Allowed
Amount for any secondary surgical
procedure(s) performed. In addition,
Coinsurance or Copayment (if any) indicated
in your Schedule of Benefits will apply. This
guideline is applicable to all bilateral
procedures and all surgical procedures
performed on the same date of service.
2. Payment for incidental surgical procedures
is limited to the Allowed Amount for the
primary procedure, and there is no
additional payment for any incidental
procedure. An "incidental surgical
procedure" includes surgery where one, or
more than one, surgical procedure is
performed through the same incision or
operative approach as the primary surgical
procedure which, in BCBSF's or Monroe
County BOCC's opinion, is not clearly
identified and /or does not add significant
time or complexity to the surgical session.
For example, the removal of a normal
appendix performed in conjunction with a
Medically Necessary hysterectomy is an
incidental surgical procedure (i.e., there is
no payment for the removal of the normal
appendix in the example).
3. Payment for surgical procedures for fracture
care, dislocation treatment, debridement,
wound repair, unna boot, and other related
Health Care Services, is included in the
Allowed Amount of the surgical procedure.
Transplant Services
Transplant Services, limited to the procedures
listed below, may be covered when performed at
a facility acceptable to BCBSF or Monroe
County BOCC, subject to the conditions and
limitations described below.
Transplant includes pre - transplant, transplant
and post- discharge Services, and treatment of
complications after transplantation. Benefits will
only be paid for Services, care and treatment
received or provided in connection with a:
1. Bone Marrow Transplant, as defined herein,
which is specifically listed in the rule 596-
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;
What Is Covered? 2 -19
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;
8. pancreas transplant performed
simultaneously with a kidney transplant; or
9. lung -whole single or whole 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 carrier, organization or person other
than the donor's family or estate.
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.
Exclusions:
Expenses for the following are excluded:
1. transplant procedures not included in the list
above, or otherwise excluded under this
Booklet (e.g., Experimental or Investigational
transplant procedures);
2. transplant procedures involving the
transplantation or implantation of any non-
human organ or tissue;
3. transplant procedures related to the donation
or acquisition of an organ or tissue for a
recipient who is not covered under this
Benefit Booklet;
4. transplant procedures involving the implant of
an artificial organ, including the implant of the
artificial organ;
5. any organ, tissue, marrow, or stem cells
which is /are sold rather than donated;
6. any Bone Marrow Transplant, as defined
herein, which is not specifically listed in rule
5913- 12.001 of the Florida Administrative
Code or any successor or similar rule or
covered by Medicare pursuant to a national
coverage decision made by the Centers for
Medicare and Medicaid Services as
evidenced in the most recently published
Medicare Coverage Issues Manual;
7. any Service in connection with the
identification of a donor from a local, state or
national listing, except in the case of a Bone
Marrow Transplant;
8. any non - medical costs, including but not
limited to, temporary lodging or transportation
costs for you and /or your family to and from
the approved facility; and
9. any artificial heart or mechanical device that
replaces either the atrium and /or the
ventricle.
What Is Covered? 2 -20
Section 3: What Is Not Covered?
Introduction
Your Booklet expressly excludes expenses for
the following Health Care Services, supplies,
drugs or charges. The following exclusions are
in addition to any exclusions specified in the
"What Is Covered ?" section or any other section
of the Booklet.
Abortions which are elective.
Arch Supports, shoe inserts designed to effect
conformational changes in the foot or foot
alignment, orthopedic shoes, over - the - counter,
custom -made or built -up shoes, cast shoes,
sneakers, ready -made compression hose or
support hose, or similar type devices /appliances
regardless of intended use, except for
therapeutic shoes (including inserts and /or
modifications) for the treatment of severe
diabetic foot disease.
clinical ecology; chelation therapy;
thermography; mind -body interactions such as
meditation, imagery, yoga, dance, and art
therapy; biofeedback; prayer and mental
healing; manual healing methods such as the
Alexander technique, aromatherapy, Ayurvedic
massage, craniosacral balancing, Feldenkrais
method, Hellerwork, polarity therapy, Reichian
therapy, reflexology, rolfing, shiatsu, traditional
Chinese massage, Trager therapy, trigger -point
myotherapy, and biofield therapeutics; Reiki,
SHEN therapy, and therapeutic touch;
bioelectromagnetic applications in medicine; and
herbal therapies.
Complications of Non - Covered Services,
including the diagnosis or treatment of any
Condition which is a complication of a non -
covered Health Care Service (e.g., Health Care
Services to treat a complication of cosmetic
surgery are not covered).
Assisted Reproductive Therapy (Infertility)
including, but not limited to, associated Services,
supplies, and medications for In Vitro
Fertilization (IVF); Gamete Intrafallopian
Transfer (GIFT) procedures; Zygote
Intrafallopian Transfer (ZIFT) procedures;
Artificial Insemination (AI); embryo transport;
surrogate parenting; donor semen and related
costs including collection and preparation; and
infertility treatment medication.
Autopsy or postmortem examination services,
unless specifically requested by BCBSF or
Monroe County BOCC.
Complementary or Alternative Medicine
including, but not limited to, self -care or self -help
training; homeopathic medicine and counseling;
Ayurvedic medicine such as lifestyle
modifications and purification therapies;
traditional Oriental medicine including
acupuncture; naturopathic medicine;
environmental medicine including the field of
Contraceptive medications, devices,
appliances, or other Health Care Services when
provided for contraception, except when
indicated as covered, under the Preventive
Health Services category of the "What Is
Covered ?" section.
Cosmetic Services, including any Service to
improve the appearance or self - perception of an
individual (except as covered under the Breast
Reconstructive Surgery category), including and
without limitation: cosmetic surgery and
procedures or supplies to correct hair loss or
skin wrinkling (e.g., Minoxidil, Rogaine, Retin -A),
and hair implants /transplants,or services used to
improve the gender specific appearance of an
individual including, but not limited to reduction
thyroid chondroplasty, liposuction, rhinoplasty,
facial bone reconstruction, face lift,
blepharoplasty, voice modification surgery, hair
removal /hairplasty, breast augmentation.
What Is Not Covered? 3 -1
Costs related to telephone consultations (except
as indicated as covered under the Preventive
Health Services category of the COVERED
SERVICES section) , failure to keep a scheduled
appointment, or completion of any form and /or
medical information.
Custodial Care and any service of a custodial
nature, including and without limitation: Health
Care Services primarily to assist in the activities
of daily living; rest homes; home companions or
sitters; home parents; domestic maid services;
respite care; and provision of services which are
for the sole purposes of allowing a family
member or caregiver of a Covered Person to
return to work.
Dental Care or treatment of the teeth or their
supporting structures or gums, or dental
procedures, including but not limited to:
extraction of teeth, restoration of teeth with or
without fillings, crowns or other materials,
bridges, cleaning of teeth, dental implants,
dentures, periodontal or endodontic procedures,
orthodontic treatment (e.g., braces), intraoral
prosthetic devices, palatal expansion devices,
bruxism appliances, and dental x -rays. This
exclusion also applies to Phase II treatments (as
defined by the American Dental Association) for
TMJ dysfunction. This exclusion does not apply
to an Accidental Dental Injury and the Child Cleft
Lip and Cleft Palate Treatment Services
category as described in the "What Is Covered ?"
section.
Drugs
1. Prescribed for uses other than the Food and
Drug Administration (FDA) approved label
indications. This exclusion does not apply to
any drug that has been proven safe,
effective and accepted for the treatment of
the specific medical Condition for which the
drug has been prescribed, as evidenced by
the results of good quality controlled clinical
studies published in at least two or more
peer- reviewed full length articles in
respected national professional medical
journals. This exclusion also does not apply
to any drug prescribed for the treatment of
cancer that has been approved by the FDA
for at least one indication, provided the drug
is recognized for treatment of your particular
cancer in a Standard Reference
Compendium or recommended for treatment
of your particular cancer in Medical
Literature. Drugs prescribed for the
treatment of cancer that have not been
approved for any indication are excluded.
2. All drugs dispensed to, or purchased by, you
from a pharmacy. This exclusion does not
apply to drugs dispensed to you when:
a. you are an inpatient in a Hospital,
Ambulatory Surgical Center, Skilled
Nursing Facility, Psychiatric Facility or a
Hospice facility;
b. you are in the outpatient department of
a Hospital;
3. dispensed to your Physician for
administration to you in the Physician's
office and prior coverage authorization has
been obtained (if required); Any non -
Prescription medicines, remedies, vaccines,
biological products (except insulin),
pharmaceuticals or chemical compounds,
vitamins, mineral supplements, fluoride
products, over - the - counter drugs, products,
or health foods, except as described in the
Preventive Health Services category of the
"What Is Covered ?" section.
4. Any drug which is indicated or used for
sexual dysfunction (e.g., Cialis, Levitra,
Viagra, Caverject). The exception described
in exclusion number one above does not
apply to sexual dysfunction drugs excluded
under this paragraph.
5. Any Self- Administered Prescription Drug not
indicated as covered in the "What Is
Covered ?" section of this Benefit Booklet.
What Is Not Covered? 3 -2
6. Blood or blood products used to treat
hemophilia, except when provided to you
for:
a. emergency stabilization;
b. during a covered inpatient stay; or
c. when proximately related to a surgical
procedure.
The exceptions to the exclusion for drugs
purchased or dispensed by a pharmacy
described in subparagraph number two do
not apply to hemophilia drugs excluded
under this subparagraph.
7. Drugs, which require prior coverage
authorization when prior coverage
authorization is not obtained.
8. Specialty Drugs used to increase height or
bone growth (e.g., growth hormone) except
for Conditions of growth hormone deficiency
documented with two abnormally low
stimulation tests of less than 10 ng /ml and
one abnormally low growth hormone
dependent peptide or for Conditions of
growth hormone deficiency associated with
loss of pituitary function due to trauma,
surgery, tumors, radiation or disease, or for
state mandated use as in patients with
AIDS.
Continuation of growth hormone therapy will
not be covered except for Conditions
associated with significant growth hormone
deficiency when there is evidence of
continued responsiveness to treatment.
(See "What is Covered ?" section for
additional information.)
Experimental or Investigational Services,
except as otherwise covered under the Bone
Marrow Transplant provision of the Transplant
Services category.
Food and Food Products prescribed or not,
except as covered in the Enteral Formulas
subsection of the "What Is Covered ?" section.
Foot Care which is routine, including any Health
Care Service, in the absence of disease. This
exclusion includes, but is not limited to: non-
surgical treatment of bunions; flat feet; fallen
arches; chronic foot strain; trimming of toenails
corns, or calluses.
General Exclusions include, but are not limited
to:
1. any Health Care Service received prior to
your Effective Date or after the date your
coverage terminates;
2. any Service to diagnose or treat any
Condition resulting from or in connection
with yourjob or employment;
3. any Health Care Services not within the
service categories described in the "What is
Covered ?" section, any rider, or
Endorsement attached hereto, unless such
services are specifically required to be
covered by applicable law;
4. any Health Care Service you render to
yourself or those rendered by a Physician or
other health care Provider related to you by
blood or marriage;
5. any Health Care Service which is not
Medically Necessary as determined by us or
Monroe County BOCC and defined in this
Booklet. The ordering of a Service by a
health care Provider does not in itself make
such Service Medically Necessary or a
Covered Service;
6. any Health Care Services rendered at no
charge;
7. 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;
8. any Health Care Services to diagnose or
treat a Condition which, directly or indirectly,
resulted from or is in connection with:
What Is Not Covered? 3 -3
a) war or an act of war, whether declared
or not;
b) your participation in, or commission of,
any act punishable by law as a felony
whether or not you are charged or
convicted, or which constitutes riot, or
rebellion except for an injury resulting
from an act of domestic violence or a
medical condition;
c) your engaging in an illegal occupation,
except for an injury resulting from an act
of domestic violence or a medical
condition;
d) Services received at military or
government facilities to treat a condition
arising out of your service in the armed
forces, reserves and /or National Guard;
or
e) Services received to treat a Condition
arising out of your service in the armed
forces, reserves and /or National Guard;
f) Services that are not patient- specific, as
determined solely by us.
9. Health Care Services rendered because
they were ordered by a court, unless such
Services are Covered Services under this
Benefit Booklet; and
10. any Health Care Services rendered by or
through a medical or dental department
maintained by or on behalf of an employer,
mutual association, labor union, trust, or
similar person or group; or
11. Health Care Services that are not direct,
hands -on, and patient specific, including, but
not limited to the oversight of a medical
laboratory to assure timeliness, reliability,
and /or usefulness of test results, or the
oversight of the calibration of laboratory
machines, equipment, or laboratory
technicians.
Genetic screening, including the evaluation of
genes to determine if you are a carrier of an
abnormal gene that puts you at risk for a
Condition, except as provided under the
Preventive Health Services category of the
"What Is Covered ?" section.
Hearing Aids (external or implantable) and
Services related to the fitting or provision of
hearing aids, including tinnitus maskers,
batteries, and cost of repair.
Immunizations except those covered under the
Preventive Health Services category of the
"What Is Covered ?" section.
Motor Vehicle Accidents Injuries and
Services you incur due to an accident involving
any motor vehicle for which no -fault insurance is
available.
Oral Surgery except as provided under the
"What Is Covered ?" section.
Orthomolecular Therapy including nutrients,
vitamins, and food supplements.
Oversight of a medical laboratory by a
Physician or other health care Provider.
"Oversight" as used in this exclusion shall,
include, but is not limited to, the oversight of:
1. the laboratory to assure timeliness,
reliability, and /or usefulness of test results;
2. the calibration of laboratory machines or
testing of laboratory equipment;
3. the preparation, review or updating of any
protocol or procedure created or reviewed
by a Physician or other health care Provider
in connection with the operation of the
laboratory; and
4. laboratory equipment or laboratory
personnel for any reason.
Personal Comfort, Hygiene or Convenience
Items and Services deemed to be not Medically
Necessary and not directly related to your
treatment including, but not limited to:
1. beauty and barber services;
2. clothing including support hose;
What Is Not Covered? 3-4
3. radio and television;
4. guest meals and accommodations;
5. telephone charges;
6. take -home supplies;
7. travel expenses (other than Medically
Necessary Ambulance Services);
8. motel /hotel accommodations;
9. air conditioners, furnaces, air filters, air or
water purification systems, water softening
systems, humidifiers, dehumidifiers, vacuum
cleaners or any other similar equipment and
devices used for environmental control or to
enhance an environmental setting;
10. hot tubs, Jacuzzis, heated spas, pools, or
memberships to health clubs;
11. heating pads, hot water bottles, or ice packs;
12. physical fitness equipment;
13. hand rails and grab bars; and
14. Massages except as covered in the "What Is
Covered ?" section of this Booklet.
Private Duty Nursing Care rendered at any
location.
Rehabilitative Therapies provided on an
inpatient or outpatient basis, except as provided
in the Hospital, Skilled Nursing Facility, Home
Health Care, and Outpatient Cardiac,
Occupational, Physical, Speech, Massage
Therapies and Spinal Manipulations categories
of the "What Is Covered ?" section.
Rehabilitative Therapies provided for the
purpose of maintaining rather than improving
your Condition are also excluded.
Reversal of Voluntary, Surgically- Induced
Sterility including the reversal of tubal ligations
and vasectomies.
Sexual Reassignment, or Modification
Services including, but not limited to, any Health
Care Services related to such treatment, such
as psychiatric Services.
Smoking Cessation Programs including any
service to eliminate or reduce the dependency
on, or addiction to, tobacco, including but not
limited to nicotine withdrawal programs and
nicotine products (e.g., gum, transdermal
patches, etc.),except as indicated as covered
under the Preventive Health Services category
of the WHAT IS COVERED? section.
Sports - Related devices and services used to
affect performance primarily in sports- related
activities; all expenses related to physical
conditioning programs such as athletic training,
bodybuilding, exercise, fitness, flexibility, and
diversion or general motivation.
Training and Educational Programs, or
materials, including, but not limited to programs
or materials for pain management and
vocational rehabilitation, except as provided
under the Diabetes Outpatient Self Management
category of the "What Is Covered ?" section.
Travel or vacation expenses even if prescribed
or ordered by a Provider.
Volunteer Services or Services which would
normally be provided free of charge and any
charges associated with Deductible,
Coinsurance, or Copayment (if applicable)
requirements which are waived by a health care
Provider.
Weight Control Services including any service
to lose, gain, or maintain weight, including
without limitation: any weight control /loss
program; appetite suppressants; dietary
regimens; food or food supplements; exercise
programs; equipment; whether or not it is part of
a treatment plan for a Condition.
Wigs and /or cranial prosthesis.
What Is Not Covered? 3 -5
Section 4: Medical Necessity
In order for Health Care Services to be covered
under this Booklet, such Services must meet all
of the requirements to be a Covered Service,
including being Medically Necessary, as defined
by this Benefit Booklet.
It is important to remember that any review of
Medical Necessity we undertake is solely for the
purposes of determining coverage, benefits, or
payment under the terms of this Booklet and not
for the purpose of recommending or providing
medical care. In conducting a review of Medical
Necessity, BCBSF may review specific medical
facts or information pertaining to you. Any such
review, however, is strictly for the purpose of
determining whether a Health Care Service
provided or proposed meets the definition of
Medical Necessity in this Booklet. In applying
the definition of Medical Necessity in this
Booklet to a specific Health Care Service,
coverage and payment guidelines then in effect
may be applied by BCBSF..
All decisions that require or pertain to
independent professional medical /clinical
judgement or training, or the need for medical
services, are solely your responsibility and that
of your treating Physicians and health care
Providers. You and your Physicians are
responsible for deciding what medical care
should be rendered or received and when that
care should be provided. Monroe County BOCC
is ultimately responsible for determining whether
expenses incurred for medical care are covered
under this Booklet. In making coverage
decisions, neither BCBSF nor Monroe County
BOCC will be deemed to participate in or
override your decisions concerning your health
or the medical decisions of your health care
Providers.
Examples of hospitalization and other Health
Care Services that are not Medically Necessary
include, but are not limited to:
1. staying in the Hospital because
arrangements for discharge have not been
completed;
2. use of laboratory, x -ray, or other diagnostic
testing that has no clear indication, or is not
expected to alter your treatment;
3. staying in the Hospital because supervision
in the home, or care in the home, is not
available or is inconvenient; or being
hospitalized for any Service which could
have been provided adequately in an
alternate setting (e.g., Hospital outpatient
department or at home with Home Health
Care Services); or
4. inpatient admissions to a Hospital, Skilled
Nursing Facility, or any other facility for the
purpose of Custodial Care, convalescent
care, or any other Service primarily for the
convenience of the patient or his or her
family members or a Provider.
Note: Whether or not a Health Care Service
is specifically listed as an exclusion, the fact
that a Provider may prescribe, recommend,
approve, or furnish a Health Care Service
does not mean that the Service is Medically
Necessary (as defined by this Benefit
Booklet) or a Covered Service. Please refer
to the "Definitions" section for the
definitions of "Medically Necessary" or
"Medical Necessity ".
Medical Necessity 4 -1
Section 5: Understanding Your Share of Health Care
Expenses
This section explains what your share of the
health care expenses will be for Covered
Services you receive. In addition to the
information explained in this section, it is
important that you refer to your Schedule of
Benefits to determine your share of the cost with
regard to Covered Services.
WARNING: LIMITED BENEFITS WILL BE PAID
WHEN NONPARTICIPATING PROVIDERS
ARE USED. You should be aware that when
you elect to utilize the services of a
nonparticipating provider for a covered
nonemergency service, benefit payments to the
provider are not based upon the amount the
provider charges. The basis of the payment will
be determined according to your policy's out -of-
network reimbursement benefit. Nonparticipating
providers may bill insureds for any difference in
the amount. YOU MAY BE REQUIRED TO PAY
MORE THAN THE COINSURANCE OR
COPAYMENT AMOUNT. Participating providers
have agreed to accept discounted payments for
services with no additional billing to you other
than coinsurance, copayment, and deductible
amounts. You may obtain further information
about the providers who have contracted with
your insurance plan by consulting your insurer's
website or contacting your insurer or agent
directly.
Deductible Requirement
individual Deductible and only up to the
applicable Allowed Amount. Please see your
Schedule of Benefits for more information.
Family Deductible
If your plan includes a family Deductible, after
the family Deductible has been met by your
family, neither you nor your Covered
Dependents will have any additional Deductible
responsibility for the remainder of that Benefit
Period. The maximum amount that any one
Covered Person in your family can contribute
toward the family Deductible, if applicable, is the
amount applied toward the individual Deductible
Please see your Schedule of Benefits for more
information.
Copayment Requirements
Covered Services rendered by certain Providers
or at certain locations or settings will be subject
to a Copayment requirement. This is the dollar
amount you have to pay when you receive these
Services. Please refer to your Schedule of
Benefits for the specific Covered Services which
are subject to a Copayment. Listed below is a
brief description of some of the Copayment
requirements that may apply to your plan. If the
Allowed Amount or the Provider's actual charge
for a Covered Service rendered is less than the
Copayment amount, you must pay the lesser of
the Allowed Amount or the Provider's actual
charge for the Covered Service.
Individual Deductible
This amount, when applicable, must be satisfied
by you and each of your Covered Dependents
each Benefit Period, before any payment will be
made by the Group Health Plan. Only those
charges indicated on claims received for
Covered Services will be credited toward the
1. Office Services Copayment:
If your plan is a Copayment plan, the
Copayment for Covered Services rendered
in the office (when applicable) must be
satisfied by you, for each office Service
before any payment will be made. The
office Services Copayment applies
regardless of the reason for the office visit
Understanding Your Share of Health Care Expenses 5 -1
and applies to all Covered Services
rendered in the office, with the exception of
Durable Medical Equipment, Medical
Pharmacy, Prosthetics, and Orthotics.
Generally, if more than one Covered Service
that is subject to a Copayment is rendered
during the same office visit, you will be
responsible for a single Copayment which
will not exceed the highest Copayment
specified in the Schedule of Benefits for the
particular Health Care Services rendered.
2. Inpatient Facility Copayment:
The inpatient facility Copayment must be
satisfied by you, for each inpatient
admission to a Hospital, Psychiatric Facility,
or Substance Abuse Facility, before any
payment will be made for any claim for
inpatient Covered Services. The inpatient
facility Copayment applies regardless of the
reason for the admission, and applies to all
inpatient admissions to a Hospital,
Psychiatric Facility or Substance Abuse
Facility in or outside the state of Florida.
Additionally, you will be responsible for out -
of- pocket expenses for Covered Services
provided by Physicians and other health
care professionals for inpatient admissions.
Note: Inpatient facility Copayments vary
depending on the facility chosen. (Please
see the Schedule of Benefits for more
information).
3. Outpatient Facility Copayment:
The outpatient facility Copayment may be
satisfied by you, for each outpatient visit to a
Hospital, Ambulatory Surgical Center,
Independent Diagnostic Testing Facility,
Psychiatric Facility or Substance Abuse
Facility, before any payment will be made for
any claim for outpatient Covered Services.
The Outpatient Facility Copayment applies
regardless of the reason for the visit, and
applies to all outpatient visits to a Hospital,
Psychiatric Facility or Substance Abuse
Facility in or outside the state of Florida.
Additionally, you will be responsible for out -
of- pocket expenses for Covered Services
provided by Physician and other healthcare
professionals.
Note: Outpatient facility Copayments vary
depending on the facility chosen. (Please
see the Schedule of Benefits for more
information).
Hospital Per Admission Deductible
The Hospital Per Admission Deductible (PAD)
must be satisfied by each Covered Plan
Participant, for each Hospital admission, before
any payment will be made for any claim for
inpatient Health Care Services. The Hospital
Per Admission Deductible applies regardless of
the reason for the admission, is in addition to the
Deductible requirement, and applies to all
Hospital admissions in or outside the state of
Florida.
Emergency Room Per Visit
Deductible
The Emergency Room Per Visit Deductible
(PVD) is set forth in the Schedule of Benefits.
The Emergency Room Per Visit Deductible
applies regardless of the reason for the visit, is
in addition to the Deductible, and applies to
emergency room services in or outside the state
of Florida. The Emergency Room Per Visit
Deductible must be satisfied by each Covered
Plan Participant for each visit. If the Covered
Plan Participant is admitted to the Hospital at the
time of the emergency room visit, the
Emergency Room Per Visit Deductible will be
waived.
Coinsurance Requirements
All applicable Deductible or Copayment amounts
must be satisfied before any portion of the
Allowed Amount will be paid for Covered
Services. For Services that are subject to
Coinsurance, the Coinsurance percentage of the
Understanding Your Share of Health Care Expenses 5 -2
applicable Allowed Amount you are responsible
for is listed in the Schedule of Benefits.
Out -of- Pocket Maximums
Individual out -of- pocket maximum
Once you have reached the individual out -of-
pocket maximum amount listed in the Schedule
of Benefits, you will have no additional out -of-
pocket responsibility for the remainder of that
Benefit Period and we will pay 100 percent of
the Allowed Amount for Covered Services
rendered during the remainder of that Benefit
Period.
Family out -of- pocket maximum
If your plan includes a family out -of- pocket
maximum, once your family has reached the
family out -of- pocket maximum amount listed in
the Schedule of Benefits, neither you nor your
covered family members will have any additional
out -of- pocket responsibility for the remainder of
that Benefit Period and we will pay 100 percent
of the Allowed Amount for Covered Services
rendered during the remainder of that Benefit
Period. The maximum amount any one Covered
Person in your family can contribute toward the
family out -of- pocket maximum, if applicable, is
the amount applied toward the individual out -of-
pocket maximum. Please see your Schedule of
Benefits for more information.
Note: The Deductible, PAD, PVD, any
applicable Copayments and Coinsurance
amounts will accumulate toward the out -of-
pocket maximums. Any benefit penalty
reductions, non - covered charges or any charges
in excess of the Allowed Amount will not
accumulate toward the out -of- pocket maximums.
Prior Coverage Credit
You will be given credit for the satisfaction or
partial satisfaction of any Deductible and
Coinsurance maximums met by you under a
prior group insurance, blanket insurance, or
franchise insurance or group Health
Maintenance Organization (HMO) policy or plan
maintained by Monroe County BOCC if the
coverage provided hereunder replaces such a
policy or plan. This provision only applies if the
prior group insurance, blanket insurance,
franchise insurance, HMO or plan coverage was
in effect immediately preceding the Effective
Date of the coverage provided under this Benefit
Booklet. This provision is only applicable for you
during the initial Benefit Period of coverage
under this Benefit Booklet and the following
rules apply:
1. Prior Coverage Credit for Deductible:
For the initial Benefit Period of coverage
under this Benefit Booklet only, charges
credited towards your Deductible
requirement under the prior policy or plan,
for Services rendered during the 90 -day
period immediately preceding the Effective
Date of the coverage under this Benefit
Booklet, will be credited to the Deductible
requirement under this Booklet.
2. Prior Coverage Credit for Coinsurance:
Charges credited by Monroe County
BOCC's prior policy or plan, towards your
Coinsurance Maximum, for Services
rendered during the 90 -day period
immediately preceding the Effective Date of
coverage under this Benefit Booklet, will be
credited to your out -of- pocket maximum
under this Booklet.
3. Prior coverage credit towards the Deductible
or out -of- pocket maximums will only be
given for Health Care Services which would
have been Covered Services under this
Booklet.
4. Prior coverage credit under this Booklet only
applies at the initial enrollment of the entire
Group. You and /or Monroe County BOCC
are responsible for providing BCBSF with
any information necessary for BCBSF to
apply this prior coverage credit.
Understanding Your Share of Health Care Expenses 5 -3
Benefit Maximum Carryover based on the Allowed Amount for the Covered
Services provided.
If immediately before the Effective Date of the
coverage under this Benefit Booklet, you were
covered under a prior Monroe County BOCC
group plan insured or administered by BCBSF,
amounts applied to your benefit maximums
under the prior group plan, will be applied
toward your benefit under this Booklet.
Additional Expenses You Must Pay
In addition to your share of the expenses
described above, you are also responsible for:
1. any applicable Copayments;
2. expenses incurred for non - covered
Services;
3. charges in excess of any maximum benefit
limitation listed in the Schedule of Benefits
(e.g., the Benefit Period maximums);
4. charges in excess of the Allowed Amount for
Covered Services rendered by Providers
who have not agreed to accept the Allowed
Amount as payment in full;
5. any benefit reductions;
6. payment of expenses for claims denied
because we did not receive information
requested from you regarding whether or not
you have other coverage and the details of
such coverage; and
7. charges for Health Care Services which are
excluded.
Additionally, you are responsible for any
contribution amount required by Monroe County
BOCC.
How Benefit Maximums Will Be
Credited
Only amounts actually paid for Covered
Services will be credited towards any applicable
benefit maximums. The amounts paid which are
credited towards your benefit maximums will be
Understanding Your Share of Health Care Expenses 5-4
Section 6: Physicians, Hospitals and Other Provider
Options
Introduction encouraged to select and develop a relationship
It is important for you to understand how the with an In- Network Family Physician. There are
Provider you select and the setting in which you several advantages to selecting a Family
receive Health Care Services affects how much Physician. Family Physicians are trained to
you are responsible for paying under this
Booklet. This section, along with the Schedule
of Benefits, describes the health care Provider
options available to you and the payment rules
for Services you receive.
As used throughout this section "out -of- pocket
expenses" or "out -of- pocket" refers to the
amounts you are required to pay including any
applicable Copayments, the Deductible and /or
Coinsurance amounts for Covered Services.
You are entitled to preferred provider type
benefits when you receive Covered Services
from In- Network Providers. You are entitled to
traditional program type benefits at the point of
service when you receive Covered Services
from Traditional Program Providers or BlueCard
(Out -of- State) Traditional Program Providers, in
conformity with Section 7: BlueCard (Out -of-
State) Program.
Value Choice Providers
To find a Value Choice Provider you may access
the most recent provider directory at
www.floridablue.com These Providers will be
designated under the heading Value Choice
Providers.
Provider Participation Status
With BlueOptions, you may choose to receive
Services from any Provider. However, you may
be able to lower the amount you have to pay for
Covered Services by receiving care from an In-
Network Provider. Although you have the option
to select any Provider you choose, you are
provide a broad range of medical care and can
be a valuable resource to coordinate your
overall healthcare needs. Developing and
continuing a relationship with a Family Physician
allows the physician to become knowledgeable
about you and your family's health history. A
Family Physician can help you determine when
you need to visit a specialist and also help you
find one based on their knowledge of you and
your specific healthcare needs. Types of Family
Physicians are Family Practitioners, General
Practitioners, Internal Medicine doctors and
Pediatricians. Additionally, care rendered by
Family Physicians usually results in lower out -of-
pocket expenses for you. Whether you select a
Family Physician or another type of Physician to
render Health Care Services, please remember
that using In- Network Providers may result in
lower out -of- pocket expenses for you. You
should always determine whether a Provider is
In- Network or Out -of- Network prior to receiving
Services to determine the amount you are
responsible for paying out -of- pocket.
Location of Service
In addition to the participation status of the
Provider, the location or setting where you
receive Services can affect the amount you pay.
For example, the amount you are responsible for
paying out -of- pocket will vary whether you
receive Services in a Hospital, a Provider's
office, or an Ambulatory Surgical Center.
Please refer to your Schedule of Benefits for
specific information regarding your out -of- pocket
expenses for such situations. After you and
your Physician have determined the plan of
treatment most appropriate for your care, you
Physicians, Hospitals and Other Provider Options 6 -1
should refer to the "What Is Covered ?" section
and your Schedule of Benefits to find out if the
specific Health Care Services are covered and
how much you will have to pay. You should also
consult with your Physician to determine the
most appropriate setting based on your health
care and financial needs.
To verify if a Provider is In- Network
for your plan you can:
1. If in Florida, review your current BlueOptions
Provider Directory;
2. If in Florida, access the BlueOptions
Provider directory at BCBSF's web -site at
www.floridablue.com
3. If outside of Florida, access the on -line
BlueCard Doctor and Hospital Finder at
www.floridablue.com and /or
4. Call the customer service phone number in
this Booklet or on your Identification Card to
search for PPO providers.
Please remember that changes to Provider
network participation can occur at any time.
Consequently, it is your responsibility to
determine whether a specific Provider is In-
Network at the time you receive Covered
Services.
In- Network Providers
When you use In- Network Providers, your out -
of- pocket expenses for Covered Services may
be lower. Payment will be based on the Allowed
Amount and your share of the cost will be at the
In- Network benefit level listed in the Schedule of
Benefits.
Out -of- Network Providers
When you use Out -of- Network Providers your
out -of- pocket expenses for Covered Services
will be higher. We will base our payment on the
Allowed Amount at the Coinsurance percentage
listed in the Schedule of Benefits. Further, if the
Out -of- Network Provider is a Traditional
Program Provider or a BlueCard (Out -of- State)
Traditional Program Provider, our payment to
such Provider may be under the terms of that
Provider's contract. If your Schedule of Benefits
and BlueOptions Provider directory do not
include a Provider as In- Network under your
benefit plan, the Provider is considered Out -of-
Network.
Physicians, Hospitals and Other Provider Options 6 -2
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In- Network or Out -of- Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians, Hospitals and Other Provider Options 6 -3
In- Network
Out -of- Network
What expenses
• Any applicable Copayments, Deductible(s) and /or Coinsurance requirements;
are you
0 Expenses for Services which are not covered;
responsible for
0 Expenses for Services in excess of any benefit maximum limitations;
paying?
0 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
0 NO. You are protected from
• YES. You are responsible for paying
the difference
being billed for the difference in
the difference between what we pay
between what the
the Allowed Amount and the
and the Provider's charge. However,
Provider is paid
Provider's charge when you use
if you receive Services from a
and the Provider's
In- Network Providers. The
Provider who participates in our
charge?
Provider will accept the Allowed
Traditional Program, the Provider will
Amount as payment in full for
accept our Allowed Amount as
Covered Services except as
payment in full for Covered Services
otherwise permitted under the
since such Traditional Program
terms of the Provider's contract
Providers have agreed not to bill you
and this Booklet.
for the difference. Further, under the
BlueCard (Out -of- State) Program,
when you receive Covered Services
from a BlueCard (Out -of- State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In- Network or Out -of- Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians, Hospitals and Other Provider Options 6 -3
Physicians
When you receive Covered Services from a
Physician you will be responsible for a
Copayment and /or the Deductible and the
applicable Coinsurance. Several factors will
determine your out -of- pocket expenses including
your Schedule of Benefits, whether the
Physician is In- Network or Out -of- Network, the
location of service, the type of Service rendered,
and the Physician's specialty.
Remember that the location or setting where a
Service is rendered can affect the amount you
are responsible for paying out -of- pocket. After
you and your Physician have determined the
plan of treatment most appropriate for your care,
you should refer to the Schedule of Benefits and
consult with your Physician to determine the
most appropriate setting based on your health
care and financial needs.
Refer to your Schedule of Benefits to determine
the applicable Copayments, Coinsurance
percentage and /or Deductible amount you are
responsible for paying for Physician Services.
Hospitals
Each time you receive inpatient or outpatient
Covered Services at a Hospital, in addition to
any out -of- pocket expenses related to Physician
Services, you will be responsible for out -of-
pocket expenses related to Hospital Services.
In- Network Hospitals have been divided into two
groups that are referred to as "options" on the
Schedule of Benefits. The amount you are
responsible for paying out -of- pocket is different
for each of these options. Remember that there
are also different out -of- pocket expenses for
Out -of- Network Hospitals.
Since not all Physicians admit patients to every
Hospital, it is important when choosing a
Physician that you determine the Hospitals
where your Physician has admitting privileges.
You can find out what Hospitals your Physician
admits to by contacting the Physician's office.
This will provide you with information that will
help you determine a portion of what your out -of-
pocket costs may be in the event you are
hospitalized.
Refer to your Schedule of Benefits to determine
the applicable out -of- pocket expenses you are
responsible for paying for Hospital Services.
Specialty Pharmacy
Certain medications, such as injectable, oral,
inhaled and infused therapies used to treat
complex medical Conditions are typically more
difficult to maintain, administer and monitor
when compared to traditional Drugs. Specialty
Drugs may require frequent dosage
adjustments, special storage and handling and
may not be readily available at local pharmacies
or routinely stocked by Physicians' offices,
mostly due to the high cost and complex
handling they require.
Using the Specialty Pharmacy to provide these
Specialty Drugs should lower the amount you
have to pay for these medications, while helping
to preserve your benefits.
Other Providers
With BlueOptions you have access to other
Providers in addition to the ones previously
described in this section. Other Providers
include facilities that provide alternative
outpatient settings or other persons and entities
that specialize in a specific Service(s). While
these Providers may be recognized for payment,
they may not be included as In- Network
Providers for your plan. Additionally, all of the
Services that are within the scope of certain
Providers' licenses may not be Covered
Services under this Booklet. Please refer to the
"What Is Covered ?" and "What Is Not Covered ?"
sections of this Booklet and your Schedule of
Benefits to determine your out -of- pocket
Physicians, Hospitals and Other Provider Options 6-4
expenses for Covered Services rendered by
these Providers.
You may be able to receive certain outpatient
Services at a location other than a Hospital. The
amount you are responsible for paying for
Services rendered at some alternative facilities
is generally less than if you had received those
same Services at a Hospital.
Remember that the location of service can
impact the amount you are responsible for
paying out -of- pocket. After you and your
Physician have determined the plan of treatment
most appropriate for your care, you should refer
to the Schedule of Benefits and consult with
your Physician to determine the most
appropriate setting based on your health care
and financial needs. When Services are
rendered at an outpatient facility other than a
Hospital there may be an out -of- pocket expense
for the facility Provider as well as an out -of-
pocket expense for other types of Providers.
Assignment of Benefits to Providers
Except as set forth in the last paragraph of this
section, any of the following assignments, or
attempted assignments, by you to any Provider
will not be honored:
• an assignment of the benefits due to you for
Covered Services under this Benefit
Booklet;
• an assignment of your right to receive
payments for Covered Services under this
Benefit Booklet; or
• an assignment of a claim for damage
resulting from a breach, or an alleged
breach of the terms of this Benefit Booklet.
We specifically reserve the right to honor an
assignment of benefits or payment by you to a
Provider who: 1) is In- Network under your plan
of coverage; 2) is a NetworkBlue Provider even
if that Provider is not in the panel for your plan of
coverage; 3) is a Traditional Program Provider;
4) is a BlueCard (Out -of- State) PPO Program
Provider; 5) is a BlueCard (Out -of- State)
Traditional Program Provider; 6) is a licensed
Hospital, Physician, or dentist and the benefits
which have been assigned are for care provided
pursuant to section 395.1041, Florida Statutes ;
or 7) is an Ambulance Provider that provides
transportation for Services from the location
where an "Emergency Medical Condition ",
defined in section 395.002(8) Florida Statutes,
first occurred to a Hospital, and the benefits
which have been assigned are for transportation
to care provided pursuant to section 395.1041,
Florida Statutes. A written attestation of the
assignment of benefits may be required.
Physicians, Hospitals and Other Provider Options 6 -5
Section 7: BlueCard® (Out -of- State) Program
Out -of -Area Services obligations to you. However, the Host Blue is
Overview responsible for contracting with and generally
handling all interactions with its Participating
We have a variety of relationships with other
Blue Cross and /or Blue Shield Licensees.
Generally, these relationships are called "Inter -
Plan Arrangements." These Inter -Plan
Arrangements work based on rules and
procedures issued by the Blue Cross Blue
Shield Association ( "Association "). Whenever
you access Health Care Services outside
Florida, the claim for those Services may be
processed through one of these Inter -Plan
Arrangements. The Inter -Plan Arrangements
are described below.
When you receive care outside of Florida, you
will receive it from one of two kinds of
Providers. Most Providers ( "Participating
Providers ") contract with the local Blue Cross
and /or Blue Shield Licensee in that geographic
area (`Host Blue "). Some Providers
(`Nonparticipating Providers ") don't contract
with the Host Blue. We explain below how both
kinds of Providers are paid.
Inter -Plan Arrangements Eligibility — Claim
Types
All claim types are eligible to be processed
through Inter -Plan Arrangements, as described
above, except for all dental care benefits
except when paid as medical claims /benefits,
and those prescription drug benefits or vision
care benefits that may be administered by a
third party contracted by us to provide the
specific Service or Services.
BlueCard Program
Under the BlueCard Program, when you
receive Covered Services within the geographic
area served by a Host Blue, we will remain
responsible for fulfilling our contractual
Providers.
When you receive Covered Services outside of
Florida and the claim is processed through the
BlueCard Program, the amount you pay for
Covered Services is calculated based on the
lower of:
• The billed charges for Covered Services; or
• The negotiated price that the Host Blue
makes available to us.
Often, this "negotiated price" will be a simple
discount that reflects an actual price that the Host
Blue pays to your Provider. Sometimes, it is an
estimated price that takes into account special
arrangements with your Provider or Provider
group that may include types of settlements,
incentive payments and /or other credits or
charges. Occasionally, it may be an average
price, based on a discount that results in
expected average savings for similar types of
Providers after taking into account the same
types of transactions as with an estimated price.
Estimated pricing and average pricing also take
into account adjustments to correct for over- or
underestimation of past pricing of claims, as
noted above. However, such adjustments will not
affect the price we have used for your claim
because they will not be applied after a claim has
already been paid.
Special Cases: Value -Based Programs
If you receive Covered Services under a Value -
Based Program inside a Host Blue's service area,
you will not be responsible for paying any of the
Provider Incentives, risk - sharing, and /or Care
Coordinator Fees that are a part of such an
arrangement, except when a Host Blue passes
BlueCard (Out -of- State) Program 7 -1
these fees to us through average pricing or fee
schedule adjustments. Additional information is
available upon request.
Inter -Plan Programs: Federal /State
Taxes /Surcharges /Fees
Federal or state laws or regulations may
require a surcharge, tax or other fee that
applies to self- funded accounts. If applicable,
we will include any such surcharge, tax or other
fee as part of the claim charge passed on to
you.
Nonparticipating Providers Outside Florida
When Covered Services are provided outside
of Florida by Nonparticipating Providers,
payment will be based on the Allowed Amount,
as defined in the DEFINITIONS section of the
Benefit Booklet.
BlueCard Worldwide Program
If you are outside the United States, the
Commonwealth of Puerto Rico, and the U.S.
Virgin Islands (hereinafter "BlueCard Service
Area "), you may be able to take advantage of
the BlueCard Worldwide Program when
accessing Covered Services. The BlueCard
Worldwide Program is unlike the BlueCard
Program available in the BlueCard Service
Area in certain ways. For instance, although
the BlueCard Worldwide Program assists you
with accessing a network of inpatient,
outpatient and professional Providers, the
network is not served by a Host Blue. As such,
when you receive care from Providers outside
the BlueCard Service Area, you will typically
have to pay the Providers and submit the
claims yourself to obtain reimbursement for
these Services.
If you need medical assistance services
(including locating a doctor or hospital) outside
the BlueCard Service Area, you should call the
BlueCard Worldwide Service Center at
1.800.810.BLUE (2583) or call collect at 804-
673 -1177, 24 hours a day, seven days a week.
An assistance coordinator, working with a
medical professional, can arrange a physician
appointment or hospitalization, if necessary.
Inpatient Services
In most cases, if you contact the BlueCard
Worldwide Service Center for assistance,
hospitals will not require you to pay for inpatient
Covered Services, except for your Cost Share
amounts. In such cases, the hospital will submit
your claims to the BlueCard Worldwide Service
Center to begin claims processing. However, if
you paid in full at the time of Service, you must
submit a claim to receive reimbursement for
Covered Services. You must notify us of any
non - emergency inpatient Services.
Outpatient Services
Physicians, Urgent Care Centers and other
outpatient Providers located outside the BlueCard
Service Area will typically require you to pay in
full at the time of Service. You must submit a
claim to obtain reimbursement for Covered
Services.
Submitting a BlueCard Worldwide Claim
When you pay for Covered Services outside the
BlueCard Service Area, you must submit a claim
to obtain reimbursement. For institutional and
professional claims, you should complete a
BlueCard Worldwide International claim form and
send the claim form with the Provider's itemized
bill(s) to the BlueCard Worldwide Service Center
(the address is on the form) to initiate claims
processing. Following the instructions on the
claim form will help ensure timely processing of
your claim. The claim form is available from the
BlueCard Worldwide Service Center or online at
www.bluecardworldwide.com If you need
assistance with your claim submission, you
should call the BlueCard Worldwide Service
Center at 800 - 810 -BLUE (2583) or call collect at
804 - 673 -1177, 24 hours a day, seven days a
week..
BlueCard (Out -of- State) Program 7 -2
Section 8: Blueprint for Health Programs
Introduction
BCBSF has established (and from time to time
establishes) various customer - focused health
education and information programs as well as
benefit utilization management and utilization
review programs. Under the terms of the ASO
Agreement between BCBSF and Monroe
County BOCC, BCBSF has agreed to make
these programs available to you. These
programs, collectively called the Blueprint for
Health Programs, are designed to 1) provide you
with information that will help you make more
informed decisions about your health, 2) help
facilitate the management and review of
coverage and benefits provided under this
Booklet and 3) present opportunities, as
explained below, to mutually agree upon
alternative benefits or payment alternatives for
cost - effective medically appropriate Health Care
Services. Some BluePrint For Health
Programs may not be available outside the
state of Florida.
Admission Notification
The admission notification requirements vary
depending on whether you are admitted to a
Hospital, Psychiatric Facility, Substance Abuse
Facility or Skilled Nursing Facility which is In-
Network or Out -of- Network.
Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility (as applicable) if we
have been notified of your admission. For an
admission outside of Florida, you or the
Hospital, Psychiatric Facility, Substance Abuse
Facility or Skilled Nursing Facility (as applicable)
should notify us of the admission. Making sure
that we are notified of your admission will enable
us to provide you information about the Blueprint
for Health Programs available to you. You or
the Hospital, Psychiatric Facility, Substance
Abuse Facility or Skilled Nursing Facility (as
applicable) may notify us of your admission by
calling the toll free customer service number on
your ID card.
Out -of- Network
For admissions to an Out -of- Network Hospital,
Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility, you or the Hospital,
Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility should notify BCBSF of
the admission. Notifying BCBSF of your
admission will enable BCBSF to provide you
information about the Blueprint for Health
Programs available to you. You or the Hospital
may notify BCBSF of your admission by calling
the toll -free customer service number on your ID
card.
In- Network
Under the admission notification requirement,
we must be notified of all inpatient admissions
(i.e., elective, planned, urgent or emergency) to
In- Network Hospitals, Psychiatric Facilities,
Substance Abuse Facilities or Skilled Nursing
Facilities. While it is the sole responsibility of
the In- Network Provider located in Florida to
comply with our admission notification
requirements, you should ask the Hospital,
Inpatient Facility Program
Under the inpatient facility program, we may
review Hospital stays, Hospice, Inpatient
Rehabilitation, LTAC and Skilled Nursing Facility
(SNF) Services, and other Health Care Services
rendered during the course of an inpatient stay
or treatment program. We may conduct this
review while you are inpatient, after your
discharge, or as part of a review of an episode
of care when you are transferred from one level
Blueprint for Health Programs 8 -1
of inpatient care to another for ongoing
treatment. The review is conducted solely to
determine whether we should provide coverage
and /or payment for a particular admission or
Health Care Services rendered during that
admission. Using our established criteria then in
effect, a concurrent review of the inpatient stay
may occur at regular intervals, including in
advance of a transfer from one inpatient facility
to another. We will provide notification to your
Physician when inpatient coverage criteria are
no longer met. In administering the inpatient
facility program, we may review specific medical
facts or information and assess, among other
things, the appropriateness of the Services
being rendered, health care setting and /or the
level of care of an inpatient admission or other
health care treatment program. Any such
reviews by us, and any reviews or assessments
of specific medical facts or information which we
conduct, are solely for purposes of making
coverage or payment decisions under this
Benefit Booklet and not for the purpose of
recommending or providing medical care.
Provider Focused Utilization
Management Program
Certain NetworkBlue Providers have agreed to
participate in our focused utilization
management program. This pre- service review
program is intended to promote the efficient
delivery of medically appropriate Health Care
Services by NetworkBlue Providers. Under this
program we may perform focused prospective
reviews of all or specific Health Care Services
proposed for you. In order to perform the
review, we may require the Provider to submit to
us specific medical information relating to Health
Care Services proposed for you. These
NetworkBlue Providers have agreed not to bill,
or collect, any payment whatsoever from you or
us, or any other person or entity, with respect to
a specific Health Care Service if:
1. they fail to submit the Health Care Service
for a focused prospective review when
required under the terms of their agreement
with us; or
2. we perform a focused review under the
focused utilization management program
and we determine that a Health Care
Service is not Medically Necessary in
accordance with our Medical Necessity
criteria or inconsistent with our benefit
guidelines then in effect unless the following
exception applies.
Exception for Certain NetworkBlue Physicians
Certain NetworkBlue Physicians licensed as
Doctors of Medicine (M.D.) or Doctors of
Osteopathy (D.O.) only may bill you for Services
determined to be not Medically Necessary by
BCBSF under this focused utilization
management program if, before you receive the
Service:
a. they give you a written estimate of your
financial obligation for the Service;
b. they specifically identify the proposed
Service that BCBSF has determined not to
be Medically Necessary; and
c. you agree to assume financial responsibility
for such Service.
Prior Coverage Authorization/Pre-
Service Notification Programs
It is important for you to understand our prior
coverage authorization programs and how the
Provider you select and the type of Service you
receive affects these requirements and
ultimately how much you are responsible for
paying under this Benefit Booklet.
You or your Provider will be required to obtain
prior coverage authorization from us for:
1. advanced diagnostic imaging Services,
such as CT scans, MRIs, MRA and nuclear
imaging;
2. Autism Spectrum Disorder; and
Blueprint for Health Programs 8 -2
3. other Health Care Services that are or may
become subject to a prior coverage
authorization program or a pre- service
notification program as defined and
administered by us.
Prior coverage authorization requirements vary,
depending on whether Services are rendered by
an In- Network Provider or an Out -of- Network
Provider, as described below:
In- Network Providers
It is the In- Network Provider's sole responsibility
to comply with our prior coverage authorization
requirements, and therefore you will not be
responsible for any benefit reductions if prior
coverage authorization is not obtained before
Medically Necessary Services are rendered.
Once we have received the necessary medical
documentation from the Provider, we will review
the information and make a prior coverage
authorization decision, based on our established
criteria then in effect. The Provider will be
notified of the prior coverage authorization
decision.
Out -of- Network Providers
In the case of advanced diagnostic
imaging Services such as CT scans, MRIs,
MRA and nuclear imaging, it is your sole
responsibility to comply with our prior
coverage authorization requirements when
rendered or referred by an Out -of- Network
Provider before the advanced diagnostic
imaging Services are provided. Your
failure to obtain prior coverage
authorization will result in denial of
coverage for such Services.
For additional details on how to obtain prior
coverage authorization for advanced
diagnostic imaging Services, please call the
customer service phone number on the back
of your ID Card.
2. In the case of Autism Spectrum Disorder,
under a prior coverage authorization or pre -
service notification program, it is your sole
responsibility to comply with our prior
coverage authorization or pre- service
notification requirements when rendered or
referred by an Out -of- Network Provider,
before the Services are provided. Failure
to obtain prior coverage authorization
will result in denial of coverage for such
Services.
3. In the case of other Health Care Services
under a prior coverage authorization or pre -
service notification program, it is your sole
responsibility to comply with our prior
coverage authorization or pre- service
notification requirements when rendered or
referred by an Out -of- Network Provider,
before the Services are provided. Failure
to obtain prior coverage authorization or
provide pre - service notification may
result in denial of the claim or application
of a financial penalty assessed at the
time the claim is presented for payment
to us. The penalty applied will be the lesser
of $500 or 20% of the total Allowed Amount
of the claim. The decision to apply a penalty
or deny the claim will be made uniformly and
will be identified in the notice describing the
prior coverage authorization and pre- service
notification programs.
Once the necessary medical documentation has
been received from you and /or the Out -of-
Network Provider, BCBSF or a designated
vendor, will review the information and make a
prior coverage authorization decision, based on
our established criteria then in effect. You will
be notified of the prior coverage authorization
decision.
BCBSF will provide you information for any Out -
of- Network Health Care Service subject to a
prior coverage authorization or pre- service
notification program, including how you can
Blueprint for Health Programs 8 -3
obtain prior coverage authorization and /or
provide the pre- service notification for such
Service not already listed here. This information
will be provided to you upon enrollment, or at
least 30 days prior to such Out -of- Network
Services becoming subject to a prior coverage
authorization or pre- service notification program.
See the "Claims Processing" section for
information on what you can do if prior coverage
authorization is denied.
Note: Prior coverage authorization is not
required when Covered Services are provided
for the treatment of an Emergency Medical
Condition.
Member Focused Programs
The Blueprint for Health Programs may include
voluntary programs for certain members. These
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
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
made available on a case -by -case basis when
you meet BCBSF's case management criteria
then in effect. Such alternative benefits or
payments, if any, will be made available in
accordance with a treatment plan with which
you, or your representative, and your Physician
agree to in writing. In addition, Monroe County
BOCC will be required to specifically agree to
such treatment plan and the alternative benefits
or payment.
The fact that certain Health Care Services under
the personal case management program have
been provided or payment has been made in no
way obligates BCBSF, Monroe County BOCC,
or the Group Health Plan to continue to provide
or pay for the same or similar Services. Nothing
contained in this section shall be deemed a
waiver of Monroe County BOCC's right to
enforce this Booklet in strict accordance with its
terms. The terms of this Booklet will continue to
apply, except as specifically modified in writing
in accordance with the personal case
management program rules then in effect.
Blueprint for Health Programs 8 -4
Health Information, Promotion, Prevention
and Illness Management Programs
These Blueprint for Health Programs may
include health information that supports health
care education and choices for healthcare
issues. These programs focus on keeping you
well, help to identify early preventive measures
of treatment and help covered individuals with
chronic problems to enjoy lives that are as
productive and healthy as possible. These
programs may include prenatal educational
programs and illness management programs for
Conditions such as diabetes, cancer and heart
disease. These programs are voluntary and are
designed to enhance your ability to make
informed choices and decisions for your unique
health care needs. You may call the toll free
customer service number on your ID card for
more information. Your participation in this
program is completely voluntary
IMPORTANT INFORMATION RELATING TO
BCBSF'S BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain to
independent professional medical /clinical
judgment or training, or the need for medical
services, are solely your responsibility and the
responsibility of your Physicians and other
health care Providers. You and your Physicians
are responsible for deciding what medical care
should be rendered or received, and when and
how that care should be provided. Monroe
County BOCC is ultimately responsible for
determining whether expenses, which have
been or will be incurred for medical care are, or
will be, covered under this Booklet. In fulfilling
this responsibility, neither BCBSF nor Monroe
County BOCC will be deemed to participate in or
override the medical decisions of your health
care Provider.
Please note that the Hospital admission
notification requirement and any Blueprint For
Health Program may be discontinued or
modified at any time without notice to you or
your consent.
Blueprint for Health Programs 8 -5
Section 9: Eligibility for Coverage
Each employee or other individual who is eligible
to participate in the Monroe County BOCC
Group Health Plan, and who meets and
continues to meet the eligibility requirements
described in this Booklet, shall be entitled to
apply for coverage under this Booklet. These
eligibility requirements are binding upon you
and /or your eligible family members. No
changes in the eligibility requirements will be
permitted except as permitted by Monroe
County BOCC. Acceptable documentation may
be required as proof that an individual meets
and continues to meet the eligibility
requirements such as a court order naming the
Eligible Employee as the legal guardian or
appropriate adoption documentation described
in the "Enrollment and Effective Date of
Coverage" section.
Eligibility Requirements for Covered
Plan Participants
In order to be eligible to enroll as a Covered
Plan Participant, an individual must be an
Eligible Employee or Eligible Retiree. An
Eligible Employee must meet each of the
following requirements:
1. The employee must be a bona fide
employee of a Monroe County Employer,
participating in the Monroe County Group
Health Plan;
2. The employee must be actively working 25
hours or more per week on a regular basis;
3. The employee must have completed the
applicable Waiting Period of 60 days of
continuous service; and
4. The employee must meet any additional
eligibility requirement(s) required by Monroe
County BOCC.
Note: Employees and qualified Dependents are
eligible for coverage on the day following the
60th day of continuous service or Waiting
Period.
Monroe County BOCC's coverage eligibility
classifications may be expanded to include:
1. retired employees;
2. additional job classifications;
3. Constitutional Officers or their Employees
4. employees of affiliated or subsidiary
companies of Monroe County BOCC; and
5. other individuals as determined by Monroe
County BOCC.
Monroe County BOCC shall have sole discretion
concerning the expansion of eligibility
classifications.
Eligibility Requirements for
Dependent(s)
An individual who meets the eligibility criteria
specified below is an Eligible Dependent and is
eligible to apply for coverage under this Booklet:
1. The Covered Plan Participant's spouse
under a legally valid existing marriage.
2. The Covered Plan Participant's natural,
newborn, adopted, Foster, or step child(ren)
(or a child for whom the Covered Plan
Participant has been court- appointed as
legal guardian or legal custodian) who has
not reached the end of the Calendar Year in
which he or she reaches age 26 (or in the
case of a Foster Child, is no longer eligible
under the Foster Child Program), regardless
of the dependent child's student or marital
status, financial dependency on the Covered
Plan Participant, whether the dependent
child resides with the Covered Plan
Eligibility For Coverage 9 -1
Participant, or whether the dependent child
is eligible for or enrolled in any other group
health plan.
3. The newborn child of a Covered Dependent
child who has not reached the end of the
Calendar Year in which he or she becomes
26. Coverage for such newborn child will
automatically terminate 18 months after the
birth of the newborn child.
Note: If a Covered Dependent child who has
reached the end of the Calendar Year in which
he or she becomes 26 obtains a dependent of
their own (e.g., through birth or adoption) such
newborn child will not be eligible for this
coverage and the Covered Dependent child will
also lose his or her eligibility for this coverage. It
is the Covered Plan Participant's sole
responsibility to establish that a child meets the
applicable requirements for eligibility.
This eligibility shall terminate on the last day of
the Calendar Year in which the dependent child
reaches age 26.
Extension of Eligibility for Dependent
Children
A Covered Dependent child may continue
coverage beyond the end of the Calendar Year
in which he or she reaches age 26, provided he
or she is:
1. unmarried and does not have a dependent;
2. a Florida resident or a full -time or part-time
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.
This eligibility shall terminate on the last day of
the Calendar Year in which the dependent child
reaches age 30.
Handicapped Children
In the case of a handicapped dependent child,
such child is eligible to continue coverage as a
Covered Dependent, beyond the age of 26, if
the child is:
1. otherwise eligible for coverage under the
Group Health Plan;
2. incapable of self- sustaining employment by
reason of mental retardation or physical
handicap; and
3. chiefly dependent upon the Covered Plan
Participant for support and maintenance
provided that the symptoms or causes of the
child's handicap existed prior to the child's
26th birthday.
This eligibility shall terminate on the last day of
the month in which the dependent child no
longer meets the requirements for extended
eligibility as a handicapped child.
Exception for Students on Medical Leave of
Absence from School
A Covered Dependent child who is a full -time or
part-time student at an accredited post-
secondary institution, who takes a physician
certified medically necessary leave of absence
from school, will still be considered a student for
eligibility purposes under this Booklet for the
earlier of 12 months from the first day of the
leave of absence or the date the Covered
Dependent would otherwise no longer be eligible
for coverage under this Booklet.
Eligibility For Coverage 9 -2
Section 10: Enrollment and Effective Date of Coverage
Eligible Employees, Eligible Retiree and Eligible
Dependents may enroll for coverage according
to the provisions below.
Employee /Retiree and the employee's spouse
under a legally valid existing marriage or
Domestic Partner.
Any Eligible Employee, Eligible Retiree or
Eligible Dependent who is not properly enrolled
will not be covered under this Benefit Booklet.
Neither BCBSF nor Monroe County BOCC will
have any obligation whatsoever to any individual
who is not properly enrolled.
Any Employee, Eligible Retiree or Eligible
Dependent who is eligible for coverage under
this Booklet may apply for coverage according to
the provisions set forth below.
Employee /Child(ren) Coverage - This type of
coverage provides coverage for the
Employee /Retiree and the covered child(ren)
only.
Employee /Family Coverage - This type of
coverage provides coverage for the
Employee /Retiree and the Eligible Retiree
Covered Dependents.
There may be additional contribution amounts
for each Covered Dependent based on the
coverage selected by Monroe County BOCC.
Enrollment Forms /Electing Coverage
To apply for coverage, you as the Eligible
Employee , Eligible Retiree must:
1. complete and submit, through Monroe
County BOCC Benefits Office, the
Enrollment Form;
2. provide any additional information needed to
determine eligibility, at the request of
BCBSF or Monroe County BOCC Benefits
Office;
Enrollment Periods
The enrollment periods for applying for coverage
are as follows:
Initial Enrollment Period is the period of time
during which an Eligible Employee or Eligible
Dependent is first eligible to enroll. It starts on
the Eligible Employee's or Eligible Dependent's
initial date of eligibility and ends no less than 30
days later.
3. pay any required contribution; and
4. complete and submit, through Monroe
County BOCC Benefits Office, an
Enrollment Form to add Eligible
Dependents.
When making application for coverage, you
must elect one of the types of coverage
available under Monroe County BOCC's
program. Such types may include:
Employee Only Coverage - This type of
coverage provides coverage for the
Employee /Retiree only.
Employee /Spouse Coverage - This type of
coverage provides coverage for the
Annual Open Enrollment Period is the period
of time during which each Eligible Employee or
Eligible Retiree is given an opportunity to select
coverage from among the alternatives included
in Monroe County BOCC's health benefit
program. The period is established by Monroe
County BOCC, occurs annually, and will take
place when specified by Monroe County BOCC.
Special Enrollment Period is the 30 -day period
of time (unless otherwise noted) immediately
following a special circumstance during which an
Eligible Employee or Eligible Dependent may
apply for coverage. Special circumstances are
described in the Special Enrollment Period
subsection.
Enrollment and Effective Date of Coverage 10 -1
Employee Enrollment
An Eligible Employee who fails to enroll during
the Initial Enrollment Period will not be covered
and may only enroll under this Benefit Booklet
during the next Annual Open Enrollment Period
established by Monroe County BOCC, or in the
case of a Special Enrollment event, during the
Special Enrollment Period. The Effective Date
will be the date specified by Monroe County
BOCC.
Dependent Enrollment
An individual may be added upon becoming an
Eligible Dependent of a Covered Plan
Participant. Below are special rules for certain
Eligible Dependents.
Newborn Child — To enroll a newborn child who
is an Eligible Dependent, the Covered Plan
Participant must submit an Enrollment Form to
BCBSF through Monroe County BOCC Benefits
Office during the 30 -day period immediately
following the date of birth. The Effective Date of
coverage for a newborn child will be the date of
birth.
If timely notice is given, no additional
contribution will be charged for coverage of the
newborn child for not less than 30 days after the
birth of the child. If timely notice is not received,
the applicable contribution will be charged from
the date of birth. The applicable contribution for
the child will be charged after the initial 30 -day
period in either case. Coverage will not be
denied for a newborn child if the Covered Plan
Participant provides notice to Monroe County
BOCC Benefits Office and an Enrollment Form
is received within the 60 -day period of the birth
of the child and any applicable contribution is
paid back to the date of birth.
If the newborn is not enrolled within sixty days of
the date of birth, the newborn child will not be
covered, and may only be enrolled under this
Benefit Booklet during an Annual Open
Enrollment Period, or in the case of a Special
Enrollment event, during the Special Enrollment
Period.
Note: For a Covered Dependent child who has
reached the end of the Calendar Year in which
he or she becomes 26 and the Covered
Dependent child obtains a dependent of their
own (e.g., through birth or adoption), such
newborn child will not be eligible for this
coverage and cannot enroll. Further, such
Covered Dependent child will also lose his or
her eligibility for this coverage.
Adopted Newborn Child — To enroll an
adopted newborn child, the Covered Plan
Participant must submit an Enrollment Form
through Monroe County BOCC Benefits Office to
BCBSF during the 30 -day period immediately
following the date of birth. The Effective Date of
coverage for an adopted newborn child, eligible
for coverage, will be the moment of birth,
provided that a written agreement to adopt such
child has been entered into by the Covered Plan
Participant prior to the birth of such child,
whether or not such an agreement is
enforceable. The Covered Plan Participant may
be required to provide any information and /or
documents that are deemed necessary in order
to administer this provision.
If timely notice is given, no additional
contribution will be charged for coverage of the
adopted newborn child for not less than 30 days
after the birth of the child. If timely notice is not
received, the applicable contribution will be
charged from the date of birth. The applicable
contribution for the child will be charged after the
initial 30 -day period in either case. Coverage
will not be denied for an adopted newborn child
if the Covered Plan Participant provides notice
to Monroe County BOCC Benefits Office and an
Enrollment Form is received within the 60 -day
period of the birth of the adopted newborn child
and any applicable contribution is paid back to
the date of birth.
If the adopted newborn child is not enrolled
within sixty days of the date of birth, the adopted
Enrollment and Effective Date of Coverage 10 -2
newborn child will not be covered, and may only
be enrolled under this Benefit Booklet during an
Annual Open Enrollment Period, or in the case
of a Special Enrollment event, during the Special
Enrollment Period.
If the adopted newborn child is not ultimately
placed in the residence of the Covered Plan
Participant, there shall be no coverage for the
adopted newborn child. It is your responsibility
as the Covered Plan Participant to notify Monroe
County BOCC Benefits Office within ten
calendar days of the date that placement was to
occur if the adopted newborn child is not placed
in your residence.
Adopted /Foster Children — To enroll an
adopted or Foster Child, the Covered Plan
Participant must submit an Enrollment Form
during the 30 -day period immediately following
the date of placement. The Effective Date for an
adopted or Foster child (other than an adopted
newborn child) will be the date such adopted or
Foster child is placed in the residence of the
Covered Plan Participant in compliance with
applicable law. The Covered Plan Participant
may be required to provide any information
and /or documents deemed necessary in order to
properly administer this section.
In the event Monroe County BOCC Benefits
Office is not notified within 30 days of the date of
placement, the child will be added as of the date
of placement so long as Covered Plan
Participant provides notice to Monroe County
BOCC Benefits Office, and we receive the
Enrollment Form within 60 days of the
placement. If the adopted or Foster Child is not
enrolled within sixty days of the date of
placement, the adopted or Foster Child will not
be covered, and may only be enrolled under this
Benefit Booklet during an Annual Open
Enrollment Period, or in the case of a Special
Enrollment event, during the Special Enrollment
Period. For all children covered as adopted
children, if the final decree of adoption is not
issued, coverage shall not be continued for the
proposed adopted Child. Proof of final adoption
must be submitted to BCBSF through Monroe
County BOCC Benefits Office. It is the
responsibility of the Covered Plan Participant to
notify BCBSF through Monroe County BOCC
Benefits Office if the adoption does not take
place. Upon receipt of this notification, we will
terminate the coverage of the child as of the
Effective Date of the adopted child upon receipt
of the written notice.
If the Covered Plan Participant's status as a
foster parent is terminated, coverage will end for
any Foster Child. It is the responsibility of the
Covered Plan Participant to notify BCBSF
through Monroe County BOCC Benefits Office
that the Foster Child is no longer in the Covered
Plan Participant's care. Upon receipt of this
notification, coverage for the child will be
terminated on the date the Covered Plan
Participant's status as a foster parent
terminated.
Marital Status —The Covered Plan Participant
may apply for coverage of an Eligible Dependent
due to a legally valid existing marriage. To
apply for coverage, the Covered Plan Participant
must complete the Enrollment Form through
Monroe County BOCC Benefits Office and
forward it to BCBSF. The Covered Plan
Participant must make application for enrollment
within 30 days of the marriage. The Effective
Date of coverage for an Eligible Dependent who
is enrolled as a result of marriage is the date of
the marriage.
Court Order — The Covered Plan Participant
may apply for coverage for an Eligible
Dependent outside of the Initial Enrollment
Period and Annual Open Enrollment Period if a
court has ordered coverage to be provided for a
minor child under their group coverage. To
apply for coverage, the Covered Plan Participant
must complete an Enrollment Form through
Monroe County BOCC Benefits Office and
forward it to BCBSF. The Covered Plan
Participant must make application for enrollment
within 30 days of the court order. The Effective
Date of coverage for an Eligible Dependent who
Enrollment and Effective Date of Coverage 10 -3
is enrolled as a result of a court order is the date
required by the court.!
Annual Open Enrollment Period
Eligible Employees and /or Eligible Dependents
who did not apply for coverage during the Initial
Enrollment Period or a Special Enrollment
Period may apply for coverage during an Annual
Open Enrollment Period. The Eligible Employee
may enroll by completing the Enrollment Form
during the Annual Open Enrollment Period.
The effective date of coverage for an Eligible
Employee and any Eligible Dependent(s) will be
the date established by Monroe County BOCC
Benefits Office.
Eligible Employees who do not enroll or change
their coverage selection during the Annual Open
Enrollment Period, must wait until the next
Annual Open Enrollment Period, unless the
Eligible Employee or the Eligible Dependent is
enrolled due to a special circumstance as
outlined in the Special Enrollment Period
subsection of this section.
Special Enrollment Period
An Eligible Employee and /or the Employee's
Eligible Dependent(s) may apply for coverage
outside of the Initial Enrollment Period and
Annual Enrollment Period as a result of a special
enrollment event. To apply for coverage, the
Eligible Employee and /or the Employee's
Eligible Dependent(s) must complete the
applicable Enrollment Form and forward it to the
Monroe County BOCC Benefits Office within the
time periods noted below for each special
enrollment event.
An Eligible Employee and /or the Employee's
Eligible Dependent(s) may apply for coverage if
one of the following special enrollment events
occurs and the applicable Enrollment Form is
submitted to the Monroe County BOCC Benefits
Office within the indicated time periods:
1. If you lose your coverage under another
group health benefit plan (as an employee
or dependent), or coverage under other
health insurance (except in the case of loss
of coverage under a Children's Health
Insurance Program (CHIP) or Medicaid, see
#3 below), or COBRA continuation
coverage that you were covered under at
the time of initial enrollment provided that:
a) when offered coverage under this plan
at the time of initial eligibility, you stated,
in writing, that coverage under a group
health plan or health insurance
coverage was the reason for declining
enrollment; and
b) you lost your other coverage under a
group health benefit plan or health
insurance coverage (except in the case
of loss of coverage under a CHIP or
Medicaid, see #3 below) as a result of
termination of employment, reduction in
the number of hours you work, reaching
or exceeding the maximum lifetime of all
benefits under other health coverage,
the employer ceased offering group
health coverage, death of your spouse,
divorce, legal separation or employer
contributions toward such coverage was
terminated; and
c) you submit the applicable Enrollment
Form to the Group within 30 days of the
date your coverage was terminated
Note: Loss of coverage for failure to pay
your required contribution /premium on a
timely basis or for cause (such as making a
fraudulent claim or an intentional
misrepresentation of a material fact in
connection with the prior health coverage) is
not a qualifying event for special enrollment.
or
2. If when offered coverage under this plan at
the time of initial eligibility, you stated, in
writing, that coverage under a group health
plan or health insurance coverage was the
Enrollment and Effective Date of Coverage 10 -4
reason for declining enrollment; and you get
married or obtain a dependent through birth,
adoption or placement in anticipation of
adoption and you submit the applicable
Enrollment Form to the Monroe County
BOCC Benefits Office within 30 days of the
date of the event.
or
3. If you or your Eligible Dependent(s) lose
coverage under a CHIP or Medicaid due to
loss of eligibility for such coverage or
become eligible for the optional state
premium assistance program and you
submit the applicable Enrollment Form to
the Monroe County BOCC Benefits Office
within 60 days of the date such coverage
was terminated or the date you become
eligible for the optional state premium
assistance program.
The Effective Date of coverage for you and your
Eligible Dependents added as a result of a
special enrollment event is the date of the
special enrollment event. Eligible Employees or
Eligible Dependents who do not enroll or change
their coverage selection during the Special
Enrollment Period must wait until the next
Annual Open Enrollment Period (See the
Dependent Enrollment subsection of this section
for the rules relating to the enrollment of Eligible
Dependents of a Covered Plan Participant).
Other Provisions Regarding
Enrollment and Effective Date of
Coverage
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, unless the employer has
indicated that the employee qualifies for the
exception as described in the federal
regulations. The provisions of the Group Health
Plan (which includes this Booklet), which are
applicable to newly hired employees and their
Eligible Dependents (e.g., enrollment, Effective
Dates of coverage, Pre - existing Condition
exclusionary period, and Waiting Period) are
applicable to rehired employees and their
Eligible Dependents if the employee does not
qualify for the federal exception.
Enrollment and Effective Date of Coverage 10 -5
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
A Covered Plan Participant's coverage under
this Benefit Booklet will automatically terminate
at 12:01 a.m.:
any of the applicable eligibility requirements;
5. date specified by Monroe County BOCC that
the Dependent's coverage is terminated for
cause (see the Termination of Individual
1. on the date the Group Health Plan
terminates;
2. on the date the ASO Agreement between
BCBSF and Monroe County BOCC
terminates;
3. on the last day of the first month that the
Covered Plan Participant fails to continue to
meet any of the applicable eligibility
requirements;
4. on the date specified by Monroe County
BOCC that the Covered Plan Participant's
coverage is terminated for cause (see the
Termination of an Individual Coverage for
Cause subsection); or
5. on the date specified by Monroe County
BOCC that the Covered Plan Participant's
coverage terminates.
Termination of a Covered
Dependent's Coverage
A Covered Dependent's coverage will
automatically terminate at 12:01 a.m. on the
date:
1. the Group Health Plan terminates;
2. the Covered Plan Participant's coverage
Coverage for Cause subsection).
In the event you as the Covered Plan Participant
wish to delete a Covered Dependent from
coverage, an Enrollment Form must be
forwarded to BCBSF through Monroe County
BOCC Benefits Office.
In the event you as the Covered Plan Participant
wish to terminate a spouse's coverage, (e.g., in
the case of divorce), you must submit an
Enrollment Form to Monroe County BOCC, prior
to the requested termination date or within 10
days of the date the divorce is final, whichever is
applicable.
Termination of an Individual's
Coverage for Cause
In the event any of the following occurs, Monroe
County BOCC may terminate an individual's
coverage for cause:
1. fraud, material misrepresentation or
omission in applying for coverage or
benefits; or
2. the knowing misrepresentation, omission or
the giving of false information on Enrollment
Forms or other forms completed, by or on
your behalf.
terminates for any reason;
3. the Dependent becomes covered under an
alternative health benefits plan which is
offered through or in connection with the
Group Health Plan;
Notice of Termination
It is Monroe County BOCC's responsibility to
immediately notify you of your termination or that
of your Covered Dependents for any reason.
Termination of Coverage 11 -1
Section 12: Continuing Coverage Under COBRA
A federal continuation of coverage law, known
as the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA), as
amended, may apply to your Group Health Plan.
If COBRA applies, you or your Covered
Dependents may be entitled to continue
coverage for a limited period of time, if you meet
the applicable requirements, make a timely
election, and pay the proper amount required to
maintain coverage.
You must contact Monroe County BOCC
Benefits Office to determine if you or your
Covered Dependent(s) are entitled to COBRA
continuation of coverage. Monroe County
BOCC is solely responsible for meeting all of the
obligations under COBRA, including the
obligation to notify all Covered Persons of their
rights under COBRA. If you fail to meet your
obligations under COBRA and this Benefit
Booklet, Monroe County BOCC will not be liable
for any claims incurred by you or your Covered
Dependent(s) after termination of coverage.
A summary of your COBRA rights and the
general conditions for qualification for COBRA
continuation coverage is provided below.
The following is a summary of what you may
elect, if COBRA applies to Monroe County
BOCC and you are eligible for such coverage:
months) if you or your Covered
Dependent(s) is /are totally disabled (as
defined by the Social Security Administration
(SSA)) at the time of your termination,
reduction in hours or within the first 60 days
of COBRA continuation coverage. The
Covered Person must supply notice of the
disability determination to Monroe County
BOCC Benefits Office within 18 months of
becoming eligible for continuation coverage
and no later than 60 days after the SSA's
determination date.
2. Your Covered Dependent(s) may elect to
continue their coverage for a period not to
exceed 36 months in the case of:
a) the Covered Plan Participant's
entitlement to Medicare;
b) divorce or legal separation of the
Covered Plan Participant;
c) death of the Covered Plan Participant;
d) the employer files bankruptcy (subject to
bankruptcy court approval); or
e) a dependent child may elect the 36
month extension if the dependent child
ceases to be an Eligible Dependent
under the terms of Monroe County
BOCC's coverage.
1. You may elect to continue this coverage for
a period not to exceed 18 months* in the
case of:
a) termination of employment of the
Covered Plan Participant other than for
gross misconduct; or
b) reduced hours of employment of the
Covered Plan Participant.
*Note: You and /or your Covered
Dependent(s) are eligible for an 11 month
extension of the 18 month COBRA
continuation option above (to a total of 29
Children born to or placed for adoption with the
Covered Plan Participant during the continuation
coverage periods noted above are also eligible
for the remainder of the continuation period.
Additional requirements applicable to
continuation of coverage under COBRA are set
forth below:
1. Monroe County BOCC must notify you of
your continuation of coverage rights under
COBRA within 14 days of the event which
creates the continuation option. If coverage
would be lost due to Medicare entitlement,
Continuing Coverage Under COBRA 12 -1
divorce, legal separation or the failure of a
Covered Dependent child to meet eligibility
requirements, you or your Covered
Dependent must notify Monroe County
BOCC Benefits Office, in writing, within 60
days of any of these events. Monroe
County BOCC's 14 -day notice requirement
runs from the date of receipt of such notice
2. You must elect to continue the coverage
within 60 days of the later of:
a) the date that the coverage terminates; or
b) the date the notification of continuation of
coverage rights is sent by 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.
An election by a Covered Plan Participant or
Covered Dependent spouse shall be deemed to
be an election for any other qualified beneficiary
related to that Covered Plan Participant or
Covered Dependent spouse, unless otherwise
specified in the election form.
Note: This section shall not be interpreted to
grant any continuation rights in excess of
those required by COBRA and /or Section
4980B of the Internal Revenue Code.
Additionally, this Benefit Booklet shall be
deemed to have been modified, and shall be
interpreted, so as to comply with COBRA
and changes to COBRA that are mandatory
with respect to Monroe County BOCC.
Continuing Coverage Under COBRA 12 -2
Section 13: Conversion Pr
Eligibility Criteria for Conversion
You are entitled to apply for a BCBSF individual
insurance conversion policy (hereinafter referred
to as a "converted policy" or "conversion policy ")
if:
1. you were continuously covered for at least
three months under the Group Health Plan,
and /or under another group policy that
provided similar benefits immediately prior to
the Group Health Plan; and
2. your coverage was terminated for any
reason, including discontinuance of the
Group Health Plan in its entirety and
termination of continued coverage under
COBRA.
Notify BCBSF in writing or by telephone if you
are interested in a conversion policy. Within 14
days of such notice, BCBSF will send you a
conversion policy application, premium notice
and outline of coverage. The outline of
coverage will contain a brief description of the
benefits and coverage, exclusions and
limitations, and the applicable Deductible(s) and
Coinsurance provisions.
BCBSF must receive a completed application
for a converted policy, and the applicable
premium payment, within the 63 -day period
beginning on the date the coverage under
the Group Health Plan terminated. If
coverage has been terminated, due to the
non - payment of employee contribution by
Monroe County BOCC, BCBSF must receive
the completed converted policy application
and the applicable premium payment within
the 63 -day period beginning on the date
notice was given that the Group Health Plan
terminated.
In the event BCBSF does not receive the
converted policy application and the initial
premium payment within such 63 -day period,
your converted policy application will be denied
and you will not be entitled to a converted policy.
ivilege
Additionally, you are not entitled to a converted
policy if:
1. you are eligible for or covered under the
Medicare program;
2. you failed to pay, on a timely basis, the
contribution required for coverage under the
Group Health Plan;
3. the Group Health Plan was replaced within
31 days after termination by any group
policy, contract, plan, or program, including
a self- insured plan or program, that provides
benefits similar to the benefits provided
under this Booklet; or
4. a) you fall under one of the following
categories and meet the requirements of
4.b. below:
you are covered under any Hospital,
surgical, medical or major medical
policy or contract or under a
prepayment plan or under any other
plan or program that provides
benefits which are similar to the
benefits provided under this Booklet;
or
ii. you are eligible, whether or not
covered, under any arrangement of
coverage for individuals in a group,
whether on an insured, uninsured,
or partially insured basis, for
benefits similar to those provided
under this Booklet; or
iii. benefits similar to the benefits
provided under this Booklet are
provided for or are available to you
pursuant to or in accordance with
the requirements of any state or
federal law (e.g., COBRA,
Medicaid); and
Conversion Privilege 13 -1
b) the benefits provided under the sources
referred to in paragraph 4.a.i or the
benefits provided or available under the
source referred to in paragraph 4.a.ii.
and 4.a.iii. above, together with the
benefits provided by our converted
policy would result in over - insurance in
accordance with our over - insurance
standards, as determined by us.
Neither Monroe County BOCC nor BCBSF
has any obligation to notify you of this
conversion privilege when your coverage
terminates or at any other time. It is your
sole responsibility to exercise this
conversion privilege by submitting a BCBSF
converted policy application and the initial
premium payment to us within 63 days of the
termination of your coverage under this
Benefit Booklet. The converted policy may
be issued without evidence of insurability
and shall be effective the day following the
day your coverage under this Benefit Booklet
terminated.
Note: Our converted policies are not a
continuation of coverage under COBRA or any
other states' similar laws. Coverage and
benefits provided under a converted policy will
not be identical to the coverage and benefits
provided under this Booklet. When applying for
our converted policy, you have two options: 1) a
converted policy providing major medical
coverage meeting the requirements of
627.6675(10) Florida Statutes or 2) a converted
policy providing coverage and benefits identical
to the coverage and benefits required to be
provided under a small employer standard
health benefit plan pursuant to Section
627.6699(12) Florida Statutes. In any event, we
will not be required to issue a converted policy
unless required to do so by Florida law. We
may have other options available to you. Call
the telephone number on your Identification card
for more information.
Conversion Privilege 13 -2
Section 14: Extension of Benefits
Extension of Benefits
In the event the Group Health Plan is
terminated, coverage will not be provided under
this Benefit Booklet for any Service rendered on
or after the termination date. The extension of
benefits provisions described below only apply
when the entire Group Health Plan is
terminated. The extension of benefits described
in this section do not apply when your coverage
terminates if the Group Health Plan remains in
effect. The extension of benefits provisions are
subject to all of the other provisions, including
the limitations and exclusions.
Note: It is your sole responsibility to provide
acceptable documentation showing that you are
entitled to an extension of benefits.
In the event you are totally disabled on the
termination date of the Group Health Plan as
a result of a specific Accident or illness
incurred while you were covered under this
Booklet, as determined by us, a limited
extension of benefits will be provided under
this Benefit Booklet for the disabled
individual only. This extension of benefits is
for Covered Services necessary to treat the
disabling Condition only. This extension of
benefits will only continue as long as the
disability is continuous and uninterrupted. In
any event, this extension of benefits will
automatically terminate at the end of the 12-
month period beginning on the termination
date of the Group Health Plan.
For purposes of this section, you will be
considered "totally disabled" only if, in our
or Monroe County BOCC's opinion, you are
unable to work at any gainful job for which
you are suited by education, training, or
experience, and you require regular care
and attendance by a Physician. You are
totally disabled only if, in our or Monroe
County BOCC's opinion, you are unable to
perform those normal day -to -day activities
which you would otherwise perform and you
require regular care and attendance by a
Physician.
2. In the event you are receiving covered
dental treatment as of the termination date
of the Group Health Plan a limited extension
of such covered dental treatment will be
provided under this Benefit Booklet if:
a) a course of dental treatment or dental
procedures were recommended in
writing and commenced in accordance
with the terms specified herein while you
were covered under the Group Health
Plan;
b) the dental procedures were procedures
for other than routine examinations,
prophylaxis, x -rays, sealants, or
orthodontic services; and
c) the dental procedures were performed
within 90 days after the Group Health
Plan terminated.
This extension of benefits is for Covered
Services necessary to complete the
dental treatment only. This extension of
benefits will automatically terminate at
the end of the 90 -day period beginning
on the termination date of the Group
Health Plan or on the date you become
covered under a succeeding insurance,
health maintenance organization or self -
insured plan providing coverage or
Services for similar dental procedures.
You are not required to be totally
disabled in order to be eligible for this
extension of benefits.
Please refer to the Dental Care category of
the "What Is Covered ?" section for a
description of the dental care Services
covered under this Booklet.
Extension of Benefits 14 -1
3. In the event you are pregnant as of the
termination date of the Group Health Plan, a
limited extension of the maternity expense
benefits included in this Booklet will be
available, provided the pregnancy
commenced while the pregnant individual
was covered under the Group Health Plan,
as determined by us or Monroe County
BOCC. This extension of benefits is for
Covered Services necessary to treat the
pregnancy only. This extension of benefits
will automatically terminate on the date of
the birth of the child. You are not required to
be Totally Disabled in order to be eligible for
this extension of benefits.
Extension of Benefits 14 -2
Section 15: The Effect of Medicare Coverage /Medicare
Secondary Pay
When you become covered under Medicare and
continue to be eligible and covered under this
Benefit Booklet, coverage under this Benefit
Booklet will be primary and the Medicare
benefits will be secondary, but only to the extent
required by law. In all other instances, coverage
under this Benefit Booklet will be secondary to
any Medicare benefits. To the extent the
benefits under this Benefit Booklet are primary,
claims for Covered Services should be filed with
BCBSF first.
rer Provisions
Benefit Booklet was primary prior to ESRD
entitlement, then coverage hereunder will
remain primary for the ESRD coordination
period. If you become eligible for Medicare due
to ESRD, coverage will be provided, as
described in this section, on a primary basis for
30 months.
Under Medicare, Monroe County BOCC MAY
NOT offer, subsidize, procure or provide a
Medicare supplement policy to you. Also,
Monroe County BOCC MAY NOT induce you to
decline or terminate your group health insurance
coverage and elect Medicare as primary payer.
If you become 65 or become eligible for
Medicare due to End Stage Renal Disease
( "ESRD "), you must immediately notify Monroe
County BOCC Benefits Office.
Individuals With End Stage Renal
Disease
If you are entitled to Medicare coverage
because of ESRD, coverage under this Benefit
Booklet will be provided on a primary basis for
30 months beginning with the earlier of:
1. the month in which you became entitled to
Medicare Part "A" ESRD benefits; or
2. the first month in which you would have
been entitled to Medicare Part "A" ESRD
benefits if a timely application had been
made.
If Medicare was primary prior to the time you
became eligible due to ESRD, then Medicare
will remain primary (i.e., persons entitled due to
disability whose employer has less than 100
employees, retirees and /or their spouses over
the age of 65). Also, if coverage under this
Disabled Active Individuals
If you are entitled to Medicare coverage
because of a disability other than ESRD,
Medicare benefits will be secondary to the
benefits provided under this Benefit Booklet
provided that:
Monroe County BOCC employed at least 100 or
more full -time or part -time employees on 50% or
more of its regular business days during the
previous Calendar Year. If the Group Health
Plan is a multi - employer plan, as defined by
Medicare, Medicare benefits will be secondary if
at least one employer participating in the plan
covered 100 or more employees under the plan
on 50% or more of its regular business days
during the previous Calendar Year.
Miscellaneous
1. This section shall be subject to, modified (if
necessary) to conform to or comply with,
and interpreted with reference to the
requirements of federal statutory and
regulatory Medicare Secondary Payer
provisions as those provisions relate to
Medicare beneficiaries who are covered
under this Benefit Booklet.
2. BCBSF will not be liable to Monroe County
BOCC or to any individual covered under
this Benefit Booklet on account of any
nonpayment of primary benefits resulting
from any failure of performance of Monroe
The Effect of Medicare Coverage/ Medicare Secondary Payer Provisions 15 -1
County BOCC's obligations as described in
this section.
The Effect of Medicare Coverage/ Medicare Secondary Payer Provisions 15 -2
Section 16: Duplication of Coverage Under Other Health
Plans /Programs
Coordination of Benefits
Coordination of Benefits ( "COB ") is a limitation
of coverage and /or benefits to be provided under
this Benefit Booklet.
COB determines the manner in which expenses
will be paid when you are covered under more
than one health plan, program, or policy
providing benefits for Health Care Services.
COB is designed to avoid the costly duplication
of payment for Covered Services. It is your
responsibility to provide BCBSF and Monroe
County BOCC Benefits Office information
concerning any duplication of coverage under
any other health plan, program, or policy you or
your Covered Dependents may have. This
means you must notify BCBSF and Monroe
County BOCC Benefits Office in writing if you
have other applicable coverage or if there is no
other coverage. You may be requested to
provide this information at initial enrollment, by
written correspondence annually thereafter, or in
connection with a specific Health Care Service
you receive. If the information is not received,
claims may be denied and you will be
responsible for payment of any expenses related
to denied claims.
Health plans, programs or policies which may be
subject to COB include, but are not limited to,
the following which will be referred to as
"plan(s)" for purposes of this section:
with which the law permits coordination of
benefits;
4. Medicare, as described in "The Effect of
Medicare Coverage /Medicare Secondary
Payer Provisions" section; and
5. to the extent permitted by law, any other
government sponsored health insurance
program.
The amount of payment, if any, when benefits
are coordinated under this section, is based on
whether or not the benefits under this Benefit
Booklet are primary. When primary, payment
will be made for Covered Services without
regard to coverage under other plans. When the
benefits under this Benefit Booklet are not
primary, payment for Covered Services may be
reduced so that total benefits under all your
plans will not exceed 100 percent of the total
reasonable expenses actually incurred for
Covered Services. For purposes of this section,
in the event you receive Covered Services from
an In- Network Provider or an Out -of- Network
Provider who participates in the Traditional
Program, "total reasonable expenses" shall
mean the total amount required to be paid to the
Provider pursuant to the applicable agreement
BCBSF or another Blue Cross and /or Blue
Shield organization has with such Provider. In
the event that the primary payer's payment
exceeds the Allowed Amount, no payment
will be made for such Services.
1. any group or non -group health insurance,
group -type self- insurance, or HMO plan;
2. any group plan issued by any Blue Cross
and /or Blue Shield organization (s);
3. any other plan, program or insurance policy,
including an automobile PIP insurance
policy and /or medical payment coverage
The following rules shall be used to establish the
order in which benefits under the respective
plans will be determined:
1. This plan always pays secondary to any
medical payment, personal injury protection
(PIP) coverage or no -fault coverage under
any automobile policy.
Duplication of Coverage Under Other Health Plans /Programs 16 -1
2. When we cover you as a Covered
Dependent and the other plan covers you as
other than a dependent, we will be
secondary.
3. When we cover you as a dependent child
and your parents are married (not separated
or divorced):
a. the plan of the parent whose birthday,
month and day, falls earlier in the year
will be primary;
b. if both parents have the same birthday,
month and day, and the other plan has
covered one of the parents longer than
us, we will be secondary.
4. When we cover you as a dependent child
whose parents are not married, or are
separated or divorced:
a. if the parent with custody is not
remarried, the plan of the parent with
custody is primary;
b. if the parent with custody has remarried,
the plan of the parent with custody is
primary; the step - parent's plan is
secondary; and the plan of the parent
without custody is last;
c. regardless of which parent has custody,
when a court decree specifies the
parent who is financially responsible for
the child's health care expenses, the
plan of that parent is always primary.
5. When we cover you as a dependent child
and the other plan covers you as a
dependent child:
a. the plan of the parent who is neither laid
off nor retired will be primary;
b. if the other plan is not subject to this
rule, and if, as a result, such plan does
not agree on the order of benefits, this
paragraph shall not apply.
6. If you have continuation of coverage under
COBRA as a result of the purchase of
coverage as provided under the
Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended,
and also under another group plan, the
following order of benefits applies:
a. first, the plan covering the person as an
employee, or as the employee's
Dependent; and
b. second, the coverage purchased under
the plan covering the person as a former
employee, or as the former employee's
Dependent provided according to the
provisions of COBRA.
7. When rules 1 through 6 above do not
establish an order of benefits, the plan which
has covered the individual the longest shall
be primary, unless you are age 65 or older
and covered under Medicare Parts A and B.
In that case, this Booklet will be secondary
to Medicare.
8. If the other plan does not have rules that
establish the same order of benefits as
under this Booklet, the benefits under the
other plan will be determined primary to the
benefits under this Booklet.
We will not coordinate benefits against an
indemnity -type policy, an excess insurance
policy, a policy with coverage limited to specified
illnesses or accidents, or a Medicare
Supplement policy.
Non - Duplication of Government
Programs and Worker's
Compensation
The benefits under this Booklet shall not
duplicate any benefits to which you or your
Covered Dependents are entitled to or eligible
for under government programs (e.g., Medicare,
Medicaid, Veterans Administration) or Worker's
Compensation to the extent allowed by law, or
Duplication of Coverage Under Other Health Plans /Programs 16 -2
under any extension of benefits of coverage
under a prior plan or program which may be
provided or required by law.
Duplication of Coverage Under Other Health Plans /Programs 16 -3
Section 17: Claims Processing
Introduction
This section is intended to:
• help you understand what you or your
treating Providers must do, under the terms
of this Benefit Booklet, in order to obtain
payment for expenses for Covered Services
they have rendered or will render to you;
and
• provide you with a general description of the
applicable procedures we will use for
making Adverse Benefit Determinations,
Concurrent Care Decisions and for notifying
you when we deny benefits.
Under no circumstances will we be held
responsible for, nor will we accept liability
relating to, the failure of your Group Plan's
sponsor or plan administrator to: 1) comply with
any applicable disclosure requirements;
2) provide you with a Summary Plan Description
(SPD); or 3) comply with any other legal
requirements. You should contact your plan
sponsor or administrator if you have questions
relating to your Group Plan's SPD. We are not
your Group Plan's sponsor or plan administrator
In most cases, a plan's sponsor or plan
administrator is the employer who establishes
and maintains the plan.
Types of Claims
For purposes of this Benefit Booklet, there are
three types of claims: 1) Pre - Service Claims;
2) Post - Service Claims; and 3) Claims Involving
Urgent Care. It is important that you become
familiar with the types of claims that can be
submitted to us and the timeframes and other
requirements that apply.
Post - Service Claims
How to File a Post - Service Claim
We have defined and described the three types
of claims that may be submitted to us. Our
experience shows that the most common type of
claim we will receive from you or your treating
Providers will likely be Post - Service Claims.
In- Network Providers have agreed to file Post -
Service Claims for Services they render to you.
In the event a Provider who renders Services to
you does not file a Post - Service Claim for such
Services, it is your responsibility to file it with us
We must receive a Post - Service Claim within 90
days of the date the Health Care Service was
rendered or, if it was not reasonably possible to
file within such 90 -day period, as soon as
possible. In any event, no Post - Service Claim
will be considered for payment if we do not
receive it at the address indicated on your ID
Card within one year of the date the Service was
rendered unless you were legally incapacitated.
For Post - Service Claims, we must receive an
itemized statement from the health care Provider
for the Service rendered along with a completed
claim form. The itemized statement must
contain the following information:
1. the date the Service was provided;
2. a description of the Service including any
applicable procedure code(s);
3. the amount actually charged by the
Provider;
4. the diagnosis including any applicable
diagnosis code(s);
5. the Provider's name and address;
6. the name of the individual who received the
Service; and
Claims Processing 17 -1
7. the Covered Plan Participant's name and
contract number as they appear on the ID
Card.
The itemized statement and claim form must be
received by us at the address indicated on your
ID Card.
Note: Special claims processing rules may
apply for Health Care Services you receive
outside the state of Florida under the BlueCard
Program (See the "BlueCard (Out -of- State)
Program" section of this Booklet).
The Processing of Post - Service Claims
We will use our best efforts to pay, contest, or
deny all Post - Service Claims for which we have
all of the necessary information, as determined
by us. Post - Service Claims will be paid,
contested, or denied within the timeframes
described below.
• Payment for Post - Service Claims
When payment is due under the terms of this
Benefit Booklet, we will use our best efforts to
pay (in whole or in part) for electronically
submitted Post - Service Claims within 20 days of
receipt. Likewise, we will use our best efforts to
pay (in whole or in part) for paper Post - Service
Claims within 40 days of receipt. You may
receive notice of payment for paper claims
within 30 days of receipt. If we are unable to
determine whether the claim or a portion of the
claim is payable because we need more or
additional information, we may contest the claim
within the timeframes set forth below.
• Contested Post - Service Claims
In the event we contest an electronically
submitted Post - Service Claim, or a portion of
such a claim, we will use our best efforts to
provide notice, within 20 days of receipt, that the
claim or a portion of the claim is contested. In
the event we contest a Post - Service Claim
submitted on a paper claim form, or a portion of
such a claim, we will use our best efforts to
provide notice, within 30 days of receipt, that the
claim or a portion of the claim is contested. Our
notice may identify: 1) the contested portion or
portions of the claim; 2) the reason(s) for
contesting the claim or a portion of the claim;
and 3) the date that we reasonably expect to
notify you of the decision. The notice may also
indicate whether additional information is
needed in order to complete processing of the
claim. If we request additional information, we
must receive it within 45 days of our request for
the information. If we do not receive the
requested information, the claim or a portion
of the claim will be adjudicated based on the
information in our possession at the time
and may be denied. Upon receipt of the
requested information, we will use our best
efforts to complete the processing of the Post -
Service Claim within 15 days of receipt of the
information.
• Denial of Post - Service Claims
In the event we deny a Post - Service Claim
submitted electronically, we will use our best
efforts to provide notice, within 20 days of
receipt, that the claim or a portion of the claim is
denied. In the event we deny a paper Post -
Service Claim, we will use our best efforts to
provide notice, within 30 days of receipt, that the
claim or a portion of the claim is denied. The
notice may identify the denied portion(s) of the
claim and the reason(s) for denial. It is your
responsibility to ensure that we receive all
information determined by us as necessary to
adjudicate a Post - Service Claim. If we do not
receive the necessary information, the claim
or a portion of the claim may be denied.
A Post - Service Claim denial is an Adverse
Benefit Determination and is subject to the
Adverse Benefit Determination standards and
appeal procedures described in this section.
Additional Processing Information for Post -
Service Claims
In any event, we will use our best efforts to pay
or deny all: 1) electronic Post - Service Claims
within 90 days of receipt of the completed claim;
Claims Processing 17 -2
and 2) Post - Service paper claims within 120
days of receipt of the completed claim. Claims
processing shall be deemed to have been
completed as of the date the notice of the claims
decision is deposited in the mail by us or
otherwise electronically transmitted. Any claims
payment relating to a Post - Service Claim that is
not made by us within the applicable timeframe
is subject to the payment of simple interest at
the rate established by the Florida Insurance
Code.
We will investigate any allegation of improper
billing by a Provider upon receipt of written
notification from you. If we determine that you
were billed for a Service that was not actually
performed, any payment amount will be adjusted
and, if applicable, a refund will be requested. In
such a case, if payment to the Provider is
reduced due solely to the notification from you,
we will pay you 20 percent of the amount of the
reduction, up to a total of $500.
Pre - Service Claims
How to File a Pre - Service Claim
This Benefit Booklet may condition coverage,
benefits, or payment (in whole or in part), for a
specific Covered Service, on the receipt by us of
a Pre - Service Claim as that term is defined
herein. In order to determine whether we must
receive a Pre - Service Claim for a particular
Covered Service, please refer to the "What Is
Covered ?" section and other applicable sections
of this Benefit Booklet. You may also call the
customer service number on your ID card for
assistance.
We are not required to render an opinion or
make a coverage or benefit determination with
respect to a Service that has not actually been
provided to you unless the terms of this Benefit
Booklet require (or condition payment upon)
approval by us for the Service before it is
received.
Benefit Determinations on Pre - Service Claims
Involving Urgent Care
For a Pre - Service Claim Involving Urgent Care,
we will use our best efforts to provide notice of
our determination (whether adverse or not) as
soon as possible, but not later than 72 hours
after receipt of the Pre - Service Claim unless
additional information is required for a coverage
decision. If additional information is necessary
to make a determination, we will use our best
efforts to provide notice within 24 hours of: 1)
the need for additional information; 2) the
specific information that you or your Provider
may need to provide; and 3) the date that we
reasonably expect to provide notice of the
decision. If we request additional information,
we must receive it within 48 hours of our
request. We will use our best efforts to provide
notice of the decision on your Pre - Service Claim
within 48 hours after the earlier of: 1) receipt of
the requested information; or 2) the end of the
period you were afforded to provide the
specified additional information as described
above.
Benefit Determinations on Pre - Service Claims
that Do Not Involve Urgent Care
We will use our best efforts to provide notice of a
decision on a Pre - Service Claim not involving
urgent care within 15 days of receipt provided
additional information is not required for a
coverage decision. This 15 -day determination
period may be extended by us one time for up to
an additional 15 days. If such an extension is
necessary, we will use our best efforts to provide
notice of the extension and reasons for it. We
will use our best efforts to provide notification of
the decision on your Pre - Service claim within a
total of 30 days of the initial receipt of the claim,
if an extension of time was taken by us.
If additional information is necessary to make a
determination, we will use our best efforts to:
1) provide notice of the need for additional
information, prior to the expiration of the initial
15 -day period; 2) identify the specific information
Claims Processing 17 -3
that you or your Provider may need to provide;
and 3) inform you of the date that we reasonably
expect to notify you of our decision. If we
request additional information, we must receive
it within 45 days of our request for the
information. We will use our best efforts to
provide notification of the decision on your Pre -
Service Claim within 15 days of receipt of the
requested information.
A Pre - Service Claim denial is an Adverse
Benefit Determination and is subject to the
Adverse Benefit Determination standards and
appeal procedures described in this section.
Concurrent Care Decisions
Reduction or Termination of Coverage or
Benefits for Services
A reduction or termination of coverage or
benefits for Services will be considered an
Adverse Benefit Determination when:
• we have approved in writing coverage or
benefits for an ongoing course of Services to
be provided over a period of time or a
number of Services to be rendered; and
• the reduction or termination occurs before
the end of such previously approved time or
number of Services; and
• the reduction or termination of coverage or
benefits by us was not due to an
amendment of this Benefit Booklet or
termination of your coverage as provided by
this Benefit Booklet.
We will use our best efforts to notify you of such
reduction or termination in advance so that you
will have a reasonable amount of time to have
the reduction or termination reviewed in
accordance with the Adverse Benefit
Determination standards and procedures
described below. In no event shall we be
required to provide more than a reasonable
period of time within which you may develop
your appeal before we actually terminate or
reduce coverage for the Services.
Requests for Extension of Services
Your Provider may request an extension of
coverage or benefits for a Service beyond the
approved period of time or number of approved
Services. If the request for an extension is for a
Claim Involving Urgent Care, we will use our
best efforts to notify you of the approval or denial
of such requested extension within 24 hours
after receipt of your request, provided it is
received at least 24 hours prior to the expiration
of the previously approved number or length of
coverage for such Services. We will use our
best efforts to notify you within 24 hours if: 1) we
need additional information; or 2) you or your
representative failed to follow proper procedures
in your request for an extension. If we request
additional information, you will have 48 hours to
provide the requested information. We may
notify you orally or in writing, unless you or your
representative specifically request that it be in
writing. A denial of a request for extension of
Services is considered an Adverse Benefit
Determination and is subject to the Adverse
Benefit Determination review procedure below.
Standards for Adverse Benefit
Determinations
Manner and Content of a Notification of an
Adverse Benefit Determination
We will use our best efforts to provide notice of
any Adverse Benefit Determination in writing.
Notification of an Adverse Benefit Determination
will include (or will be made available to you free
of charge upon request):
1. the date the Service or supply was provided;
2. the Provider's name;
3. the dollar amount of the claim, if applicable;
4. the diagnosis codes included on the claim
(e.g., ICD -9, DSM -IV), including a
description of such codes;
5. the standardized procedure code included
on the claim (e.g., Current Procedural
Claims Processing 17 -4
Terminology), including a description of such
codes;
6. the specific reason or reasons for the
Adverse Benefit Determination, including
any applicable denial code;
7. a description of the specific Benefit Booklet
provisions upon which the Adverse Benefit
Determination is based, as well as any
internal rule, guideline, protocol, or other
similar criterion that was relied upon in
making the Adverse Benefit Determination;
8. a description of any additional information
that might change the determination and
why that information is necessary;
9. a description of the Adverse Benefit
Determination review procedures and the
time limits applicable to such procedures;
10. if the Adverse Benefit Determination is
based on the Medical Necessity or
Experimental or Investigational limitations
and exclusions, a statement telling you how
to obtain the specific explanation of the
scientific or clinical judgment for the
determination; and
11. You have the right to an independent
external review through an external review
organization for certain appeals, as provided
in the Patient Protection and Affordable
Care Act of 2010.
If the claim is a Claim Involving Urgent Care, we
may notify you orally within the proper
timeframes, provided we follow -up with a written
or electronic notification meeting the
requirements of this subsection no later than
three days after the oral notification.
How to Appeal an Adverse Benefit
Determination
Except as described below, only you, or a
representative designated by you in writing,
have the right to appeal an Adverse Benefit
Determination. An appeal of an Adverse Benefit
Determination will be reviewed using the review
process described below. Your appeal must be
submitted to us in writing for an internal appeal
within 365 days of the original Adverse Benefit
Determination, except in the case of Concurrent
Care Decisions which may, depending upon the
circumstances, require you to file within a
shorter period of time from notice of the denial.
The following guidelines are applicable to
reviews of Adverse Benefit Determinations:
• We must receive your appeal of an Adverse
Benefit Determination in person or in writing;
• You may request to review pertinent
documents, such as any internal rule,
guideline, protocol, or similar criterion relied
upon to make the determination, and submit
issues or comments in writing;
• If the Adverse Benefit Determination is
based on the lack of Medical Necessity of a
particular Service or the Experimental or
Investigational exclusion, you may request,
free of charge, an explanation of the
scientific or clinical judgment relied upon, if
any, for the determination, that applies the
terms of this Benefit Booklet to your medical
circumstances;
• During the review process, the Services in
question will be reviewed without regard to
the decision reached in the initial
determination;
• We may consult with appropriate
Physicians, as necessary;
• Any independent medical consultant who
reviews your Adverse Benefit Determination
on our behalf will be identified upon request;
• If your claim is a Claim Involving Urgent
Care, you may request an expedited appeal
orally or in writing in which case all
necessary information on review may be
transmitted between you and us by
telephone, facsimile or other available
expeditious method; and
Claims Processing 17 -5
• If you wish to give someone else permission
to appeal an Adverse Benefit Determination
on your behalf, we must receive a
completed Appointment of Representative
form signed by you indicating the name of
the person who will represent you with
respect to the appeal. An Appointment of
Representative form is not required if your
Physician is appealing an Adverse Benefit
Determination relating to a Claim Involving
Urgent Care. Appointment of
Representative forms are available at
www.floridablue.com or by calling the
number on the back of your BCBSF ID Card.
Timing of Our Appeal Review on Adverse
Benefit Determinations
We will use our best efforts to review your
appeal of an Adverse Benefit Determination and
communicate the decision in accordance with
the following time frames:
• Pre - Service Claims -- within 30 days of the
receipt of your appeal; or
• Post - Service Claims -- within 60 days of the
receipt of your appeal; or
• Claims Involving Urgent Care (and requests
to extend concurrent care Services made
within 24 hours prior to the termination of the
Services) -- within 72 hours of receipt of your
request. If additional information is
necessary we will notify you within 24 hours
and we must receive the requested
additional information within 48 hours of our
request. After we receive the additional
information, we will have an additional 48
hours to make a final determination.
Note: The nature of a claim for Services (i.e.
whether it is "urgent care" or not) is judged as of
the time of the benefit determination on review,
not as of the time the Service was initially
reviewed or provided.
You, or a Provider acting on your behalf, who
has had a claim denied as not Medically
Necessary has the opportunity to appeal the
claim denial. The appeal may be directed to an
employee of BCBSF who is a licensed Physician
responsible for Medical Necessity reviews. The
appeal may be by telephone and the Physician
will respond to you, within a reasonable time, not
to exceed 15 business days. Requests for an
internal appeal should be sent to the address
below:
Blue Cross and Blue Shield of Florida, Inc.
Attention: Member Appeals
P.O. Box 44197
Jacksonville, Florida 32231 -4197
How to Request External Review of
Our Appeal Decision
If we deny your appeal and our decision involves
a medical judgment, including, but not limited to,
a decision based on Medical Necessity,
appropriateness, health care setting, level of
care or effectiveness of the Health Care Service
or treatment you requested or a determination
that the treatment is Experimental or
Investigational, you are entitled to request an
independent, external review of our decision.
Your request will be reviewed by an independent
third party with clinical and legal expertise
( "External Reviewer ") who has no association
with us. If you have any questions or concerns
during the external review process, please
contact us at the phone number listed on your ID
card or visit www.floridablue.com You may
submit additional written comments to External
Reviewer. A letter with the mailing address will
be sent to you when you file an external review.
Please note that if you provide any additional
information during the external review process it
will be shared with us in order to give us the
opportunity to reconsider the denial. Submit
your request in writing on the External Review
Request form within four months after receipt of
your denial to the below address:
Blue Cross and Blue Shield of Florida
Attention: Member External Reviews DCC9 -5
Post Office Box 44197
Jacksonville, FL 32231 -4197
Claims Processing 17 -6
If you have a medical Condition where the
timeframe for completion of a standard external
review would seriously jeopardize your life,
health or ability to regain maximum function, you
may file a request for an expedited external
review. Generally, an urgent situation is one in
which your health may be in serious jeopardy, or
in the opinion of your Physician, you may
experience pain that cannot be adequately
controlled while you wait for a decision on the
external review of your claim. Moreover
expedited external reviews may be requested for
an admission, availability of care, continued stay
or Health Care Service for which you received
Emergency Services, but have not been
discharged from a facility. Please be sure your
treating Physician completes the appropriate
form to initiate this request type. If you have any
questions or concerns during the external review
process, please contact us at the phone number
listed on your ID card or visit
www.floridablue.com You may submit
additional written comments to the External
Reviewer. A letter with the mailing address will
be sent to you when you file an external review.
Please note that if you provide any additional
information during the external review process it
will be shared with us in order to give us the
opportunity to reconsider the denial. If you
believe your situation is urgent, you may request
an expedited review by sending your request to
the address above or by fax to 904 - 565 -6637.
If the External Reviewer decides to overturn our
decision, we will provide coverage or payment
for your health care item or Service.
You or someone you name to act for you may
file a request for external review. To appoint
someone to act on your behalf, please complete
an Appointment of Representative form.
You are entitled to receive, upon written request
and free of charge, reasonable access to, and
copies of all documents relevant to your appeal
including a copy of the actual benefit provision,
guideline protocol or other similar criterion on
which the appeal decision was based.
You may request and we will provide the
diagnosis and treatment codes, as well as their
corresponding meanings, applicable to this
notice, if available.
Additional Claims Processing
Provisions
1. Release of Information /Cooperation:
In order to process claims, we may need
certain information, including information
regarding other health care coverage you
may have. You must cooperate with us in
our effort to obtain such information by,
among other ways, signing any release of
information form at our request. Failure by
you to fully cooperate with us may result in a
denial of the pending claim and we will have
no liability for such claim.
2. Physical Examination:
In order to make coverage and benefit
decisions, we may, at our expense, require
you to be examined by a health care
Provider of our choice as often as is
reasonably necessary while a claim is
pending. Failure by you to fully cooperate
with such examination shall result in a denial
of the pending claim and we shall have no
liability for such claim.
3. Legal Actions:
No legal action arising out of or in
connection with coverage under this Benefit
Booklet may be brought against us within
the 60 -day period following our receipt of the
completed claim as required herein.
Additionally, no such action may be brought
after expiration of the applicable statute of
limitations.
4. Fraud, Misrepresentation or Omission in
Applying for Benefits:
We rely on the information provided on the
itemized statement and the claim form when
processing a claim. All such information,
Claims Processing 17 -7
therefore, must be accurate, truthful and
complete. Any fraudulent statement,
omission or concealment of facts,
misrepresentation, or incorrect information
may result, in addition to any other legal
remedy we may have, in denial of the claim
or cancellation or rescission of your
coverage.
5. Explanation of Benefits Form:
All claims decisions, including denial and
claims review decisions, will be
communicated to you in writing either on an
explanation of benefits form or some other
written correspondence. This form may
indicate:
a) The specific reason or reasons for the
Adverse Benefit Determination;
b) Reference to the specific Benefit
Booklet provisions upon which the
Adverse Benefit Determination is based
as well as any internal rule, guideline,
protocol, or other similar criterion that
was relied upon in making the Adverse
Benefit Determination;
c) A description of any additional
information that would change the initial
determination and why that information
is necessary;
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
specific explanation of the scientific or
clinical judgment for the determination.
6. Circumstances Beyond Our Control:
To the extent that natural disaster, war, riot,
civil insurrection, epidemic, or other
emergency or similar event not within our
control, results in facilities, personnel or our
financial resources being unable to process
claims for Covered Services, we will have no
liability or obligation for any delay in the
payment of claims for Covered Services,
except that we will make a good faith effort
to make payment for such Services, taking
into account the impact of the event. For the
purposes of this paragraph, an event is not
within our control if we cannot effectively
exercise influence or dominion over its
occurrence or non - occurrence.
Claims Processing 17 -8
Section 18: Relationship Between the Parties
CDCTOW pospf !Dpvouz!CP DD!boe! nor Monroe County BOCC will be liable, whether
I f bni !Dbsf Qsp\yef st ! in tort or contract or otherwise, for any acts or
Neither BCBSF nor Monroe County BOCC nor
any of their officers, directors or employees
provides Health Care Services to you. Rather,
BCBSF and Monroe County BOCC are engaged
in making coverage and benefit decisions under
this Booklet. By accepting the Group health
care coverage and benefits, you agree that
making such coverage and benefit decisions
does not constitute the rendering of Health Care
Services and that health care Providers
rendering those Services are not employees or
agents of BCBSF or Monroe County BOCC. In
this regard, we and Monroe County BOCC
hereby expressly disclaim any agency
relationship, actual or implied, with any
health care Provider. BCBSF and Monroe
County BOCC do not, by virtue of making
coverage, benefit, and payment decisions,
exercise any control or direction over the
medical judgment or clinical decisions of any
health care Provider. Any decisions made under
the Group Health Plan concerning
appropriateness of setting, or whether any
Service is Medically Necessary, shall be
deemed to be made solely for purposes of
determining whether such Services are covered,
and not for purposes of recommending any
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.
omissions of any other person or organization
with which BCBSF has made or hereafter makes
arrangements for the provision of Covered
Services. BCBSF is not your agent, servant, or
representative nor is BCBSF an agent, servant,
or representative of Monroe County BOCC and
BCBSF will not be liable for any acts or
omissions, or those of Monroe County BOCC, its
agents, servants, employees, or any person or
organization with which Monroe County BOCC
has entered into any agreement or arrangement.
By acceptance of coverage and benefits
hereunder, you agree to the foregoing.
Medical Treatment Decisions -
Responsibility of Your Physician, Not
BCBSF
Any and all decisions that require or pertain to
independent professional medical judgment or
training, or the need for medical Services or
supplies, must be made solely by your family
and your treating Physician in accordance with
the patient/physician relationship. It is possible
that you or your treating Physician may conclude
that a particular procedure is needed,
appropriate, or desirable, even though such
procedure may not be covered.
Non Liability of BCBSF and Monroe
County BOCC
Neither Monroe County BOCC nor any person
covered under this Booklet is BCBSF's agent or
representative, and neither shall be liable for any
acts or omissions by BCBSF's agents, servants,
employees, or us. Additionally, neither BCBSF
Relationship Between the Parties 18 -1
Section 19: General Provisions
Access to Information
BCBSF and Monroe County BOCC have the
right to receive, from you and any health care
Provider rendering Services to you, information
that is reasonably necessary, as determined by
BCBSF and Monroe County BOCC, in order to
administer the coverage and benefits provided,
subject to all applicable confidentiality
requirements listed below. By accepting
coverage, you authorize every health care
Provider who renders Services to you, to
disclose to BCBSF and Monroe County BOCC
or to affiliated entities, upon request, all facts,
records, and reports pertaining to your care,
treatment, and physical or mental Condition, and
to permit BCBSF and /or Monroe County BOCC
to copy any such records and reports so
obtained.
Right to Receive Necessary
Information
In order to administer coverage and benefits,
BCBSF or Monroe County BOCC may, without
the consent of, or notice to, any person, plan, or
organization, obtain from any person, plan, or
organization any information with respect to any
person covered under this Booklet or applicant
for enrollment which BCBSF or Monroe County
BOCC deem to be necessary.
Laws and Regulations
The terms of coverage and benefits to be
provided under this Benefit Booklet shall be
deemed to have been modified and shall be
interpreted, so as to comply with applicable state
or federal laws and regulations dealing with
benefits, eligibility, enrollment, termination, or
other rights and duties.
Confidentiality
Except as otherwise specifically provided herein,
and except as may be required in order for us to
administer coverage and benefits, specific
medical information concerning you, received by
Providers, shall be kept confidential by us in
conformity with applicable law. Such information
may be disclosed to third parties for use in
connection with bona fide medical research and
education, or as reasonably necessary in
connection with the administration of coverage
and benefits, specifically including BCBSF's
quality assurance and Blueprint for Health
Programs. Additionally, we may disclose such
information to entities affiliated with us or other
persons or entities we utilize to assist in
providing coverage, benefits or services under
this Booklet. Further, any documents or
information which are properly subpoenaed in a
judicial proceeding, or by order of a regulatory
agency, shall not be subject to this provision.
Right to Recovery
Whenever the Group Health Plan has made
payments in excess of the maximum provided
for under this Booklet, BCBSF or Monroe
County BOCC will have the right to recover any
such payments, to the extent of such excess,
from you or any person, plan, or other
organization that received such payments.
Compliance with State and Federal
BCBSF's arrangements with a Provider may
require that we release certain claims and
medical information about persons covered
under this Booklet to that Provider even if
treatment has not been sought by or through
that Provider. By accepting coverage, you
hereby authorize us to release to Providers
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 19 -1
Benefit Booklet
You have been provided with this Benefit
Booklet and an Identification Card as evidence
of your coverage under this Benefit Booklet.
Modification of Provider Network and
the Participation Status
NetworkBlue and the Traditional Provider
Program, and the participation status of
individual Providers available through BCBSF,
are subject to change at any time by BCBSF
without prior notice to you or your approval or
that of Monroe County BOCC. Additionally,
BCBSF may, at any time, terminate or modify
the terms of any Provider contract and may
enter into additional Provider contracts without
prior notice to you, or your approval or that of
Monroe County BOCC. It is your responsibility
to determine whether a health care Provider is
an In- Network Provider at the time the Health
Care Service is rendered. Under this Booklet,
your financial responsibility may vary depending
upon a Provider's participation status.
Cooperation Required of You and
Your Covered Dependents
You must cooperate with BCBSF and Monroe
County BOCC, and must execute and submit to
us any consents, releases, assignments, and
other documents requested in order to
administer, and exercise any rights hereunder.
Failure to do so may result in the denial of
claims and will constitute grounds for termination
for cause (See the Termination of an Individual's
Coverage for Cause subsection in the
Termination Of Coverage section).
Non - Waiver of Defaults
Any failure by BCBSF or Monroe County BOCC
at any time, or from time to time, to enforce or to
require the strict adherence to any of the terms
or conditions described herein, will in no event
constitute a waiver of any such terms or
conditions. Further, it will not affect BCBSF's or
Monroe County BOCC's right at any time to
enforce any terms or conditions under this
Benefit Booklet.
Notices
Any notice required or permitted hereunder will
be deemed given if hand delivered or if mailed
by United States Mail, postage prepaid, and
addressed as listed below. Such notice will be
deemed effective as of the date delivered or so
deposited in the mail.
If to BCBSF:
To the address printed on the Identification
Card.
If to you:
To the latest address provided by you or to
your latest address on Enrollment Forms
actually delivered to us.
You must notify Monroe County BOCC
Benefits Office immediately of any
address change.
If to Monroe County BOCC:
To the address indicated by Monroe County
BOCC.
Our Obligations Upon Termination
Upon termination of your coverage for any
reason, there will be no further liability or
responsibility to you under the Group Health
Plan, except as specifically described herein
Promissory Estoppel
No oral statements, representations, or
understanding by any person can change, alter,
delete, add, or otherwise modify the express
written terms of this Booklet.
General Provisions 19 -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.floridahealthfinder.gov may be accessed
through the link provided on the Blue Cross and
Blue Shield of Florida corporate web site at
www.floridablue.com
Subrogation and Right of Recovery
The provisions of this section apply to all current
or former plan participants and also to the
parents, guardian, or other representative of a
dependent child who incurs claims and is or has
been covered by the plan. The plan's right to
recover (whether by subrogation or
reimbursement) shall apply to the personal
representative of your estate, your decedents,
minors, and incompetent or disabled persons.
"You" or "your" includes anyone on whose behalf
the plan pays benefits. No adult Covered Person
hereunder may assign any rights that it may
have to recover medical expenses from any
tortfeasor or other person or entity to any minor
child or children of said adult covered person
without the prior express written consent of the
Plan.
The plan's right of subrogation or
reimbursement, as set forth below, extend to all
insurance coverage available to you due to an
injury, illness or condition for which the plan has
paid medical claims (including, but not limited to,
liability coverage, uninsured motorist coverage,
underinsured motorist coverage, personal
umbrella coverage, medical payments coverage,
workers compensation coverage, no fault
automobile coverage or any first party insurance
coverage).
For the purpose of determining payment of
benefits, your health plan is always secondary to
automobile no -fault coverage, personal injury
protection coverage, or medical payments
coverage.
By accepting benefits under this Booklet, you
specifically acknowledge our right of subrogation
and reimbursement. These rights apply to any
claim or potential claim made by you or on your
behalf from the following sources, jncluding but
not limited to:
• Payments made by a Third Party or any
insurance company on behalf of the
Third Party;
• Any payments or awards under an
uninsured or underinsured motorist
coverage policy;
• Any Workers' Compensation or disability
award or settlement;
• Medical payments under any
automobile, homeowners' or premises
liability policy; and
• Any other payments from any source
intended to compensate you for injuries
resulting from an accident or alleged
negligence.
By accepting benefits under this Booklet, you
also agree to:
• Notify us promptly and in writing when
notice is given to any party of the
intention to investigate or pursue a
claim, or of settlement negotiations with
Third Parties, prior to entering into any
settlement agreement; and
• Notify us promptly of any amounts
recovered from Third Parties, by way of
settlement or judgment, and do not
distribute the settlement orjudgment
proceeds without Monroe County's prior
written consent.
No disbursement of any settlement proceeds or
other recovery funds from any insurance
coverage or other source will be made until the
General Provisions 19 -3
health plan's subrogation and reimbursement
interest are fully satisfied. No waiver, release of
liability or other documents executed by you
without prior notice to the consent from Monroe
County BOCC will be binding on the Monroe
County BOCC.
Subrogation
The right of subrogation means the plan is
entitled to pursue any claims that you may have
in order to recover the benefits paid by the plan.
Immediately upon paying or providing any
benefit under the plan, the plan shall be
subrogated to (stand in the place of) all of your
rights of recovery with respect to any claim or
potential claim against any party, due to an
injury, illness or condition to the full extent of
benefits provided or to be provided by the Plan.
The Plan may assert a claim or file suit in your
name and take appropriate action to assert its
subrogation claim, with or without your consent.
The plan is not required to pay you part of any
recovery it may obtain, even if it files suit in your
name.
Reimbursement
If you receive any payment as a result of an
injury, illness or condition, you agree to
reimburse the plan first from such payment for
all amounts the plan has paid and will pay as a
result of that injury, illness or condition, up to
and including the full amount of your recovery.
Constructive Trust
By accepting benefits (whether the payment of
such benefits is made to you or made on your
behalf to any provider) you agree that if you
receive any payment as a result of an injury,
illness or condition, you will serve as a
constructive trustee over those funds. Failure to
hold such funds in trust will be deemed a breach
of your fiduciary duty to the plan. No
disbursement of any settlement proceeds or
other recovery funds from any insurance
coverage or other source will be made until the
health plan's subrogation and reimbursement
interest are fully satisfied.
Lien Rights
Further, the plan will automatically have a lien to
the extent of benefits paid by the plan for the
treatment of the illness, injury or condition upon
any recovery whether by settlement, judgment
or otherwise, related to treatment for any illness,
injury or condition for which the plan paid
benefits. The lien may be enforced against any
party who possesses funds or proceeds
representing the amount of benefits paid by the
plan including, but not limited to, you, your
representative or agent, and /or any other source
that possessed or will possess funds
representing the amount of benefits paid by the
plan.
Assignment
In order to secure the plan's recovery rights, you
agree to assign to the plan any benefits or
claims or rights of recovery you have under any
automobile policy or other coverage, to the full
extent of the plan's subrogation and
reimbursement claims. This assignment allows
the plan to pursue any claim you may have,
whether or not you choose to pursue the claim.
First - Priority Claim
By accepting benefits from the plan, you
acknowledge that the plan's recovery rights are
a first priority claim and are to be repaid to the
plan before you receive any recovery for your
damages. The plan shall be entitled to full
reimbursement on a first - dollar basis from any
payments, even if such payment to the plan will
result in a recovery which is insufficient to make
you whole or to compensate you in part or in
whole for the damages sustained. The plan is
not required to participate in or pay your court
costs or attorney fees to any attorney you hire to
pursue your damage claim.
General Provisions 19 -4
Applicability to All Settlements and
Judgments
The terms of this entire subrogation and right of
recovery provision shall apply and the plan is
entitled to full recovery regardless of whether
any liability for payment is admitted and
regardless of whether the settlement or
judgment identifies the medical benefits the plan
provided or purports to allocate any portion of
such settlement or judgment to payment of
expenses other than medical expenses. The
plan is entitled to recover from any and all
settlements or judgments, even those
designated as pain and suffering, non - economic
damages and /or general damages only. The
plan's claim will not be reduced due to your own
negligence.
Cooperation
You agree to cooperate fully with the plan's
efforts to recover benefits paid. It is your duty to
notify the plan within 30 days of the date when
any notice is given to any party, including an
insurance company or attorney, of your intention
to pursue or investigate a claim to recover
damages or obtain compensation due to your
injury, illness or condition. You and your agents
agree to provide the plan or its representative's
notice of any recovery you or your agents obtain
prior to receipt of such recovery funds or within 5
days if no notice was given prior to receipt.
Further, you and your agents agree to provide
notice prior to any disbursement of settlement or
any other recovery funds obtained. You and
your agents shall provide all information
requested by the plan, the Claims Administrator
or its representative including, but not limited to,
completing and submitting any applications or
other forms or statements as the plan may
reasonably request and all documents related to
or filed in personal injury litigation. Failure to
provide this information, failure to assist the plan
in pursuit of its subrogation rights or failure to
reimburse the plan from any settlement or
recovery you receive may result in the denial of
any future benefit payments or claim until the
plan is reimbursed in full, termination of your
health benefits or the institution of court
proceedings against you.
You shall do nothing to prejudice the plan's
subrogation or recovery interest or prejudice the
plan's ability to enforce the terms of this plan
provision. This includes, but is not limited to,
refraining from making any settlement or
recovery that attempts to reduce or exclude the
full cost of all benefits provided by the plan or
disbursement of any settlement proceeds or
other recovery prior to fully satisfying the health
plan's subrogation and reimbursement interest.
You acknowledge that the plan has the right to
conduct an investigation regarding the injury,
illness or condition to identify potential sources
of recovery. The plan reserves the right to notify
all parties and his /her agents of its lien. Agents
include, but are not limited to, insurance
companies and attorneys.
You acknowledge that the plan has notified you
that it has the right pursuant to the Health
Insurance Portability & Accountability Act
( "HIPAA"), 42 U.S.C. Section 1301 et seq, to
share your personal health information in
exercising its subrogation and reimbursement
rights.
Interpretation
In the event that any claim is made that any part
of this subrogation and right of recovery
provision is ambiguous or questions arise
concerning the meaning or intent of any of its
terms, the Claims Administrator for the plan shall
have the sole authority and discretion to resolve
all disputes regarding the interpretation of this
provision.
Jurisdiction
By accepting benefits from the Plan, you agree
that any court proceeding with respect to this
General Provisions 19 -5
provision may be brought in any court of
competent jurisdiction as the plan may elect. By
accepting such benefits, you hereby submit to
each such jurisdiction, waiving whatever rights
may correspond by reason of your present or
future domicile. By accepting such benefits, you
also agree to pay all attorneys' fees the plan
incurs in successful attempts to recover
amounts the plan is entitled to under this
section.
Third Party Beneficiary
The terms and provisions of the Group Health
Plan shall be binding solely upon, and inure
solely to the benefit of, Monroe County BOCC
and individuals covered under the terms of this
Benefit Booklet, and no other person shall have
any rights, interest or claims thereunder, or
under this Benefit Booklet, or be entitled to sue
for a breach thereof as a third -party beneficiary
or otherwise. Monroe County BOCC hereby
specifically expresses its intent that health care
Providers that have not entered into contracts
with BCBSF to participate in BCBSF's Provider
networks shall not be third -party beneficiaries
under the terms of the Monroe County BOCC
Group Health Plan or this Benefit Booklet.
Customer Rewards Programs
From time to time, we may offer programs to our
customers that provide rewards for following the
terms of the program. We will tell you about any
available rewards programs in general mailings,
member newsletters and /or on our website.
Your participation in these programs is
completely voluntary and will in no way affect
the coverage available to you under this Benefit
Booklet. We reserve the right to offer rewards in
excess of $25 per year as well as the right to
discontinue or modify any reward program
features or promotional offers at any time
without your consent.
General Provisions 19 -6
Section 20: Definitions
The following definitions are used in this Benefit
Booklet. Other definitions may be found in the
particular section or subsection where they are
used.
Accident means an unintentional, unexpected
event, other than the acute onset of a bodily
infirmity or disease, which results in traumatic
injury. This term does not include injuries
caused by surgery or treatment for disease or
illness.
Accidental Dental Injury means an injury to
sound natural teeth (not previously
compromised by decay) caused by a sudden,
unintentional, and unexpected event or force.
This term does not include injuries to the mouth,
structures within the oral cavity, or injuries to
natural teeth caused by biting or chewing,
surgery, or treatment for a disease or illness.
Administrative Services Only Agreement or
ASO Agreement means an agreement between
Monroe County BOCC and BCBSF. Under the
Administrative Services Only Agreement,
BCBSF provides claims processing and
payment services, customer service, utilization
review services and access to BCBSF's
NetworkBlue and BCBSF's network of
Traditional Insurance Providers.
Adverse Benefit Determination means any
denial, reduction or termination of coverage,
benefits, or payment (in whole or in part) under
the Benefit Booklet with respect to a Pre - Service
Claim or a Post - Service Claim. Any reduction or
termination of coverage, benefits, or payment in
connection with a Concurrent Care Decision, as
described in this section, shall also constitute an
Adverse Benefit Determination.
Allowed Amount means the maximum amount
upon which payment will be based for Covered
Services. The Allowed Amount may be changed
at any time without notice to you or your
consent.
1. In the case of an In- Network Provider
located in Florida, this amount will be
established in accordance with the
applicable agreement between that Provider
and BCBSF.
2. In the case of an In- Network Provider
located outside of Florida, this amount will
generally be established in accordance with
the negotiated price that the on -site Blue
Cross and /or Blue Shield Plan ( "Host Blue ")
passes on to us, except when the Host Blue
is unable to pass on its negotiated price due
to the terms of its Provider contracts. See
the BlueCard (Out -of- State) Program
section for more details.
3. In the case of Out -of- Network Providers
located in Florida who participate in the
Traditional Program, this amount will be
established in accordance with the
applicable agreement between that Provider
and BCBSF.
4. In the case of Out -of- Network Providers
located outside of Florida who participate in
the BlueCard (Out -of- State) Traditional
Program, this amount will generally be
established in accordance with the
negotiated price that the Host Blue passes
on to us, except when the Host Blue is
unable to pass on its negotiated price due to
the terms of its Provider contracts. See the
BlueCard (Out -of- State) Program section for
more details.
5. In the case of an Out -of- Network Provider
that has not entered into an agreement with
BCBSF to provide access to a discount from
the billed amount of that Provider for the
specific Covered Services provided to you,
the Allowed Amount will be the lesser of that
Provider's actual billed amount for the
specific Covered Services or an amount
established by BCBSF that may be based
on several factors including (but not
Definitions 20 -1
necessarily limited to): (i) payment for such
Services under the Medicare and /or
Medicaid programs; (ii) payment often
accepted for such Services by that Out -of-
Network Provider and /or by other Providers,
either in Florida or in other comparable
market(s), that BCBSF determines are
comparable to the Out -of- Network Provider
that provided the specific Covered Services
(which may include payment accepted by
such Out -of- Network Provider and /or by
other Providers as participating providers in
other provider networks of third -party payers
which may include, for example, other
insurance companies and /or health
maintenance organizations); (iii) payment
amounts which are consistent, as
determined by BCBSF, with BCBSF's
provider network strategies (e.g., does not
result in payment that encourages Providers
participating in a BCBSF network to become
non - participating); and /or, (iv) the cost of
providing the specific Covered Services. In
the case of an Out -of- Network Provider that
has not entered into an agreement with
another Blue Cross and /or Blue Shield
organization to provide access to discounts
from the billed amount for the specific
Covered Services under the BlueCard (Out -
of- State) Program, the Allowed Amount for
the specific Covered Services provided to
you may be based upon the amount
provided to BCBSF by the other Blue Cross
and /or Blue Shield organization where the
Services were provided at the amount such
organization would pay non - participating
Providers in its geographic area for such
Services.
You may obtain an estimate of the Allowed
Amount for particular Services by calling the
customer service telephone number included in
this Booklet or on your Identification Card. The
fact that we may provide you with such
information does not mean that the particular
Service is a Covered Service. All terms and
conditions included in your Booklet apply. You
should refer to the "What is Covered ?" section of
your Booklet and the Schedule of Benefits to
determine what is covered and how much will be
paid.
Please specifically note that, in the case of an
Out -of- Network Provider that has not entered
into an agreement with BCBSF to provide
access to a discount from the billed amount of
that Provider, the Allowed Amount for particular
Services is often substantially below the amount
billed by such Out -of- Network Provider for such
Services. You will be responsible for any
difference between such Allowed Amount and
the amount billed for such Services by any such
Out -of- Network Provider.
Ambulance means a ground or water vehicle,
airplane or helicopter properly licensed pursuant
to Chapter 401 of the Florida Statutes, or a
similar applicable law in another state.
Ambulatory Surgical Center means a facility
properly licensed pursuant to Chapter 395 of the
Florida Statutes, or a similar applicable law of
another state, the primary purpose of which is to
provide elective surgical care to a patient,
admitted to, and discharged from such facility
within the same working day.
Applied Behavior Analysis means the design,
implementation and evaluation of environmental
modifications, using behavioral stimuli and
consequences to produce socially significant
improvement in human behavior, including, but
not limited to, the use of direct observation,
measurement and functional analysis of the
relations between environment and behavior.
Approved Clinical Trial means a phase I,
phase II, phase III, or phase IV clinical trial that
is conducted in relation to the prevention,
detection, or treatment of cancer or other Life -
Threatening Disease or Condition and meets
one of the following criteria:
Definitions 20 -2
1. The study or investigation is approved or
funded by one or more of the following:
a. The National Institutes of Health.
b. The Centers for Disease Control and
Prevention.
c. The Agency for Health Care Research
and Quality.
d. The Centers for Medicare and Medicaid
Services.
e. Cooperative group or center of any of
the entities described in clauses (i)
through (iv) or the Department of
Defense or the Department of Veterans
Affairs.
f. A qualified non - governmental research
entity identified in the guidelines issued
by the National Institutes of Health for
center support grants.
g. Any of the following if the conditions
described in paragraph (2) are met:
i. The Department of Veterans Affairs.
ii. The Department of Defense.
iii. The Department of Energy.
2. The study or investigation is conducted
under an investigational new drug
application reviewed by the Food and Drug
Administration.
3. The study or investigation is a drug trial that
is exempt from having such an
investigational new drug application.
For a study or investigation conducted by a
Department the study or investigation must be
reviewed and approved through a system of
peer review that the Secretary determines: (1) to
be comparable to the system of peer review of
studies and investigations used by the National
Institutes of Health, and (2) assures unbiased
review of the highest scientific standards by
qualified individuals who have no interest in the
outcome of the review.
For purposes of this definition, the term "Life -
Threatening Disease or Condition" means any
disease or condition from which the likelihood of
death is probable unless the course of the
disease or condition is interrupted.
Artificial Insemination (AI) means a medical
procedure in which sperm is placed into the
female reproductive tract by a qualified health
care provider for the purpose of producing a
pregnancy.
Autism Spectrum Disorder means any of the
following disorders as defined in the diagnostic
categories of the International Classification of
Diseases, Ninth Edition, Clinical Modification
(ICD -9 CM), or their equivalents in the most
recently published version of the American
Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders:
1. Autistic disorder;
2. Asperger's syndrome;
3. Pervasive developmental disorder not
otherwise specified; and
4. Childhood Disintegrative Disorder.
Benefit Period means a consecutive period of
time, specified by BCBSF and the Group, in
which benefits accumulate toward the
satisfaction of Deductibles, out -of- pocket
maximums and any applicable benefit
maximums. Your Benefit Period is listed on your
Schedule of Benefits, and will not be less than
12 months unless indicated as such.
Birth Center means a facility or institution, other
than a Hospital or Ambulatory Surgical Center,
which is properly licensed pursuant to Chapter
383 of the Florida Statutes, or a similar
applicable law of another state, in which births
are planned to occur away from the mother's
usual residence following a normal,
uncomplicated, low -risk pregnancy.
Definitions 20 -3
BlueCard (Out -of- State) Program means a
national Blue Cross and Blue Shield Association
program available through Blue Cross and Blue
Shield of Florida, Inc. Subject to any applicable
BlueCard (Out -of- State) Program rules and
protocols, you may have access to the Provider
discounts of other participating Blue Cross and /or
Blue Shield plans. See the BlueCard (Out -of-
State) Program section for more details.
BlueCard (Out -of- State) PPO Program means
a national Blue Cross and Blue Shield
Association program available through Blue
Cross and Blue Shield of Florida, Inc. Subject to
any applicable BlueCard (Out -of- State) Program
rules and protocols, you may have access to the
BlueCard (Out -of- State) PPO Program discounts
of other participating Blue Cross and /or Blue
Shield plans.
BlueCard (Out -of- State) Traditional Program
means a national Blue Cross and Blue Shield
Association program available through Blue
Cross and Blue Shield of Florida, Inc. Subject to
any applicable BlueCard (Out -of- State) Program
rules and protocols, you may have access to the
BlueCard (Out -of- State) Traditional Program
discounts of other participating Blue Cross
and /or Blue Shield plans.
BlueCard (Out -of- State) PPO Program
Provider means a Provider designated as a
BlueCard (Out -of- State) PPO Program Provider
by the Host Blue.
BlueCard (Out -of- State) Traditional Program
Provider means a Provider designated as a
BlueCard (Out -of- State) Traditional Program
Provider by the Host Blue.
Bone Marrow Transplant means human blood
precursor cells administered to a patient to
restore normal hematological and immunological
functions following ablative or non - ablative
therapy with curative or life- prolonging intent.
Human blood precursor cells may be obtained
from the patient in an autologous transplant, or
an allogeneic transplant from a medically
acceptable related or unrelated donor, and may
be derived from bone marrow, the circulating
blood, or a combination of bone marrow and
circulating blood. If chemotherapy is an integral
part of the treatment involving bone marrow
transplantation, the term "Bone Marrow
Transplant" includes the transplantation as well
as the administration of chemotherapy and the
chemotherapy drugs. The term "Bone Marrow
Transplant" also includes any Services or
supplies relating to any treatment or therapy
involving the use of high dose or intensive dose
chemotherapy and human blood precursor cells
and includes any and all Hospital, Physician or
other health care Provider Health Care Services
which are rendered in order to treat the effects
of, or complications arising from, the use of high
dose or intensive dose chemotherapy or human
blood precursor cells (e.g., Hospital room and
board and ancillary Services).
Calendar Year begins January 1st and ends
December 31 st.
Cardiac Therapy means Health Care Services
provided under the supervision of a Physician,
or an appropriate Provider trained for Cardiac
Therapy, for the purpose of aiding in the
restoration of normal heart function in
connection with a myocardial infarction,
coronary occlusion or coronary bypass surgery.
Care Coordination means organized,
information - driven patient care activities
intended to facilitate the appropriate responses
to a Covered Person's health care needs across
the continuum of care.
Care Coordinator Fee means a fixed amount
paid by a Blue Cross and /or Blue Shield
Licensee to Providers periodically for Care
Coordination under a Value -Based Program.
Certified Nurse Midwife means a person who
is licensed pursuant to Chapter 464 of the
Florida Statutes, or a similar applicable law of
another state, as an advanced nurse practitioner
Definitions 20 -4
and who is certified to practice midwifery by the
American College of Nurse Midwives.
Df stjdf e!Sf hjt d sf e!Ovst f !Bof t d f tjt u
means a person who is a properly licensed
nurse who is a certified advanced registered
nurse practitioner within the nurse anesthetist
category pursuant to Chapter 464 of the Florida
Statutes, or a similar applicable law of another
state.
Claim Involving Urgent Care means any
request or application for coverage or benefits
for medical care or treatment that has not yet
been provided to you with respect to which the
application of time periods for making non -
urgent care benefit determinations: (1) could
seriously jeopardize your life or health or your
ability to regain maximum function; or (2) in the
opinion of a Physician with knowledge of your
Condition, would subject you to severe pain that
cannot be adequately managed without the
proposed Services being rendered.
Coinsurance means your share of health care
expenses for Covered Services. After your
Deductible requirement is met, a percentage of
the Allowed Amount will be paid for Covered
Services, as listed in the Schedule of Benefits.
The percentage you are responsible for is your
Coinsurance.
Concurrent Care Decision means a decision
by us to deny, reduce, or terminate coverage,
benefits, or payment (in whole or in part) with
respect to a course of treatment to be provided
over a period of time, or a specific number of
treatments, if we had previously approved or
authorized in writing coverage, benefits, or
payment for that course of treatment or number
of treatments.
As defined herein, a Concurrent Care Decision
shall not include any decision to deny, reduce,
or terminate coverage, benefits, or payment
under the personal case management Program
as described in the "Blueprint For Health
Programs" section of this Benefit Booklet.
Dpoejypo means a disease, illness, ailment,
injury, or pregnancy.
Dpowf ojf odDbsf !Df oLf s!means a properly
licensed ambulatory center that: 1) treats a
limited number of common, low- intensity
illnesses when ready access to the patient's
primary physician is not possible; 2) shares
clinical information about the treatment with the
patient's primary physician; 3) is usually housed
in a retail business; and 4) is staffed by at least
one master's level nurse (ARNP) who operates
under a set of clinical protocols that strictly
circumscribe the conditions the ARNP can treat.
Although no physician is present at the
Convenient Care Center, medical oversight is
based on a written collaborative agreement
between a supervising physician and the ARNP
Copayment means the dollar amount
established solely by BCBSF and Monroe
County BOCC which is required to be paid to a
health care Provider by you at the time certain
Covered Services are rendered by that Provider
Cost Share means the dollar or percentage
amount established solely by us, which must be
paid to a health care Provider by you at the time
Covered Services are rendered by that Provider.
Cost Share may include, but is not limited to
Coinsurance, Copayment, Deductible and /or Per
Admission Deductible (PAD) amounts.
Applicable Cost Share amounts are identified in
your Schedule of Benefits.
Covered Dependent means an Eligible
Dependent who meets and continues to meet all
applicable eligibility requirements and who is
enrolled, and actually covered, under the Group
Health Plan other than as a Covered Plan
Participant (See the "Eligibility Requirements for
Dependent(s)" subsection of the "Eligibility for
Coverage" section).
Covered Person means a Covered Plan
Participant or a Covered Dependent.
Definitions 20 -5
Covered Plan Participant means an Eligible
Employee or other individual who meets and
continues to meet all applicable eligibility
requirements and who is enrolled, and actually
covered, under this Benefit Booklet other than
as a Covered Dependent.
Covered Services means those Health Care
Services which meet the criteria listed in the
"What Is Covered ?" section.
Custodial or Custodial Care means care that
serves to assist an individual in the activities of
daily living, such as assistance in walking,
getting in and out of bed, bathing, dressing,
feeding, and using the toilet, preparation of
special diets, and supervision of medication that
usually can be self- administered. Custodial
Care essentially is personal care that does not
require the continuing attention of trained
medical or paramedical personnel. In
determining whether a person is receiving
Custodial Care, consideration is given to the
frequency, intensity and level of care and
medical supervision required and furnished. A
determination that care received is Custodial is
not based on the patient's diagnosis, type of
Condition, degree of functional limitation, or
rehabilitation potential.
Deductible means the amount of charges, up to
the Allowed Amount, for Covered Services that
are your responsibility. The term, Deductible,
does not include any amounts you are
responsible for in excess of the Allowed Amount,
or any Coinsurance /Copay amounts, if
applicable.
Detoxification means a process whereby an
alcohol or drug intoxicated, or alcohol or drug
dependent, individual is assisted through the
period of time necessary to eliminate, by
metabolic or other means, the intoxicating
alcohol or drug, alcohol or drug dependent
factors or alcohol in combination with drugs as
determined by a licensed Physician or
Psychologist, while keeping the physiological
risk to the individual at a minimum.
Diabetes Educator means a person who is
properly certified pursuant to Florida law, or a
similar applicable law of another state, to
supervise diabetes outpatient self- management
training and educational services.
Dialysis Center means an outpatient facility
certified by the Centers for Medicare and
Medicaid Services (CMMS) and the Florida
Agency for Health Care Administration (or a
similar regulatory agency of another state) to
provide hemodialysis and peritoneal dialysis
services and support.
Dietitian means a person who is properly
licensed pursuant to Florida law or a similar
applicable law of another state to provide
nutrition counseling for diabetes outpatient self-
management services.
Down syndrome means a chromosomal
disorder caused by an error in cell division which
results in the presence of an extra whole or
partial copy of chromosome 21.
Durable Medical Equipment means equipment
furnished by a supplier or a Home Health
Agency that: 1) can withstand repeated use;
2) is primarily and customarily used to serve a
medical purpose; 3) not for comfort or
convenience; 4) generally is not useful to an
individual in the absence of a Condition; and
5) is appropriate for use in the home.
Durable Medical Equipment Provider means a
person or entity that is properly licensed, if
applicable, under Florida law (or a similar
applicable law of another state) to provide home
medical equipment, oxygen therapy services, or
dialysis supplies in the patient's home under a
Physician's prescription.
Effective Date means, with respect to
individuals covered under this Benefit Booklet,
12:01 a.m. on the date Monroe County BOCC
specifies that the coverage will commence as
further described in the "Enrollment and
Definitions 20 -6
Effective Date of Coverage" section of this
Benefit Booklet.
Eligible Dependent means an individual who
meets and continues to meet all of the eligibility
requirements described in the Eligibility
Requirements for Dependent(s) subsection of
the Eligibility for Coverage section in this Benefit
Booklet, and is eligible to enroll as a Covered
Dependent.
Eligible Employee means an active employee
or retiree individual who meets and continues to
meet all of the eligibility requirements described
in the Eligibility Requirements for Covered Plan
Participant subsection of the Eligibility for
Coverage section in the Benefit Booklet and is
eligible to enroll as a Covered Plan Participant.
Any individual who is an Eligible Employee is not
a Covered Plan Participant until such individual
has actually enrolled with, and been accepted
for coverage as a Covered Plan Participant by
Monroe County BOCC.
Emergency Medical Condition means a
medical or psychiatric Condition or an injury
manifesting itself by acute symptoms of
sufficient severity (including severe pain) such
that a prudent layperson, who possesses an
average knowledge of health and medicine,
could reasonably expect the absence of
immediate medical attention to result in a
condition described as (i) placing the health of
the individual in serious jeopardy, (ii) serious
impairment to bodily functions, or (iii) serious
dysfunction of any bodily organ or part.
Emergency Services means, with respect to an
Emergency Medical Condition:
1. a medical screening examination (as
required under Section 1867 of the Social
Security Act) that is within the capability of
the emergency department of a Hospital,
including ancillary Services routinely
available to the emergency department to
evaluate such Emergency Medical
Condition; and
2. within the capabilities of the staff and
facilities available at the hospital, such
further medical examination and treatment
as are required under Section 1867 of such
Act to Stabilize the patient.
Endorsement means an amendment to the
Group Health Plan or this Booklet.
Enrollment Date means the date of enrollment
of the individual under the Group Health Plan or,
if earlier, the first day of the Waiting Period of
such enrollment.
Enrollment Forms means those forms,
electronic (where available) or paper, which are
used to maintain accurate enrollment files under
this Benefit Booklet.
Experimental or Investigational means any
evaluation, treatment, therapy, or device which
involves the application, administration or use, of
procedures, techniques, equipment, supplies,
products, remedies, vaccines, biological
products, drugs, pharmaceuticals, or chemical
compounds if, as determined solely by BCBSF
or Monroe County BOCC:
1. such evaluation, treatment, therapy, or
device cannot be lawfully marketed without
approval of the United States Food and
Drug Administration or the Florida
Department of Health and approval for
marketing has not, in fact, been given at the
time such is furnished to you; or
2. such evaluation, treatment, therapy, or
device is provided pursuant to a written
protocol which describes as among its
objectives the following: determinations of
safety, efficacy, or efficacy in comparison to
the standard evaluation, treatment, therapy,
or device; or
3. such evaluation, treatment, therapy, or
device is delivered or should be delivered
subject to the approval and supervision of
an institutional review board or other entity
Definitions 20 -7
as required and defined by federal
regulations; or
4. credible scientific evidence shows that such
evaluation, treatment, therapy, or device is
the subject of an ongoing Phase I or II
clinical investigation, or the experimental or
research arm of a Phase III clinical
investigation, or under study to determine:
maximum tolerated dosage(s), toxicity,
safety, efficacy, or efficacy as compared
with the standard means for treatment or
diagnosis of the Condition in question; or
5. credible scientific evidence shows that the
consensus of opinion among experts is that
further studies, research, or clinical
investigations are necessary to determine:
maximum tolerated dosage(s), toxicity,
safety, efficacy, or efficacy as compared
with the standard means for treatment or
diagnosis of the Condition in question; or
6. credible scientific evidence shows that such
evaluation, treatment, therapy, or device has
not been proven safe and effective for
treatment of the Condition in question, as
evidenced in the most recently published
Medical Literature in the United States,
Canada, or Great Britain, using generally
accepted scientific, medical, or public health
methodologies or statistical practices; or
7. there is no consensus among practicing
Physicians that the treatment, therapy, or
device is safe and effective for the Condition
in question; or
8. such evaluation, treatment, therapy, or
device is not the standard treatment,
therapy, or device utilized by practicing
Physicians in treating other patients with the
same or similar Condition.
"Credible scientific evidence" shall mean (as
determined by BCBSF or Monroe County
BOCC):
1. records maintained by Physicians or
Hospitals rendering care or treatment to you
or other patients with the same or similar
Condition;
2. reports, articles, or written assessments in
authoritative medical and scientific literature
published in the United States, Canada, or
Great Britain;
3. published reports, articles, or other literature
of the United States Department of Health
and Human Services or the United States
Public Health Service, including any of the
National Institutes of Health, or the United
States Office of Technology Assessment;
4. the written protocol or protocols relied upon
by the treating Physician or institution or the
protocols of another Physician or institution
studying substantially the same evaluation,
treatment, therapy, or device;
5. the written informed consent used by the
treating Physician or institution or by another
Physician or institution studying substantially
the same evaluation, treatment, therapy, or
device; or
6. the records (including any reports) of any
institutional review board of any institution
which has reviewed the evaluation,
treatment, therapy, or device for the
Condition in question.
Note: Health Care Services which are
determined by BCBSF or Monroe County
BOCC to be Experimental or Investigational
are excluded (see the "What Is Not
Covered ?" section). In determining whether
a Health Care Service is Experimental or
Investigational, BCBSF or Monroe County
BOCC may also rely on the predominant
opinion among experts, as expressed in the
published authoritative literature, that usage
of a particular evaluation, treatment, therapy,
or device should be substantially confined to
research settings or that further studies are
necessary in order to define safety, toxicity,
effectiveness, or effectiveness compared
with standard alternatives.
Definitions 20 -8
FDA means the United States Food and Drug
Administration.
Foster Child means a person who is placed in
your residence and care under the Foster Care
Program by the Florida Department of Health &
Rehabilitative Services in compliance with
Florida Statutes or by a similar regulatory
agency of another state in compliance with that
state's applicable laws.
Gamete Intrafallopian Transfer (GIFT) means
the direct transfer of a mixture of sperm and
eggs into the fallopian tube by a qualified health
care provider. Fertilization takes place inside
the tube.
Generally Accepted Standards of Medical
Practice means standards that are based on
credible scientific evidence published in peer -
reviewed medical literature generally recognized
by the relevant medical community, Physician
Specialty Society recommendations, and the
views of Physicians practicing in relevant clinical
areas and any other relevant factors.
Gestational Surrogate means a woman,
regardless of age, who contracts, orally or in
writing, to become pregnant by means of
assisted reproductive technology without the use
of an egg from her body.
Gestational Surrogacy Contract or
Arrangement means an oral or written
agreement, regardless of the state orjurisdiction
where executed, between the Gestational
Surrogate and the intended parent or parents.
Group means the employer, labor union, trust,
association, partnership, or corporation,
department, other organization or entity through
which coverage and benefits under this Benefit
Booklet are made available to you, and through
which you and your Covered Dependents
become entitled to coverage and benefits for the
Covered Services described herein.
Group Health Plan or Group Plan means the
plan established and maintained by Monroe
County BOCC for the provision of health care
coverage and benefits to the individuals covered
under this Benefit Booklet.
Health Care Services or Services includes
treatments, therapies, devices, procedures,
techniques, equipment, supplies, products,
remedies, vaccines, biological products, drugs,
pharmaceuticals, chemical compounds, and
other services rendered or supplied, by or at the
direction of, Providers.
Home Health Agency means a properly
licensed agency or organization which provides
health services in the home pursuant to Chapter
400 of the Florida Statutes, or a similar
applicable law of another state.
Home Health Care or Home Health Care
Services means Physician- directed
professional, technical and related medical and
personal care Services provided on an
intermittent or part -time basis directly by (or
indirectly through) a Home Health Agency in
your home or residence. For purposes of this
definition, a Hospital, Skilled Nursing Facility,
nursing home or other facility will not be
considered an individual's home or residence.
Hospice means a public agency or private
organization which is duly licensed by the State
of Florida under applicable law, or a similar
applicable law of another state, to provide
hospice services. In addition, such licensed
entity must be principally engaged in providing
pain relief, symptom management, and
supportive services to terminally ill persons and
their families.
Hospital means a facility properly licensed
pursuant to Chapter 395 of the Florida Statutes,
or a similar applicable law of another state, that:
offers services which are more intensive than
those required for room, board, personal
services and general nursing care; offers
facilities and beds for use beyond 24 hours; and
regularly makes available at least clinical
laboratory services, diagnostic x -ray services
Definitions 20 -9
and treatment facilities for surgery or obstetrical
care or other definitive medical treatment of
similar extent.
The term Hospital does not include: an
Ambulatory Surgical Center; a Skilled Nursing
Facility; a stand -alone Birthing Center; a
Psychiatric Facility; a Substance Abuse Facility;
a convalescent, rest or nursing home; or a
facility which primarily provides Custodial,
educational, or Rehabilitative Therapies.
Note: If services specifically for the
treatment of a physical disability are
provided in a licensed Hospital which is
accredited by the Joint Commission on the
Accreditation of Health Care Organizations,
the American Osteopathic Association, or
the Commission on the Accreditation of
Rehabilitative Facilities, payment for these
services will not be denied solely because
such Hospital lacks major surgical facilities
and is primarily of a rehabilitative nature.
Recognition of these facilities does not
expand the scope of Covered Services. It
only expands the setting where Covered
Services can be performed for coverage
purposes.
Identification (ID) Card means the card(s)
issued to Covered Plan Participants under the
BlueOptions Group Health Plan. The card is not
transferable to another person. Possession of
such card in no way guarantees that a particular
individual is eligible for, or covered under, this
Benefit Booklet.
Independent Clinical Laboratory means a
laboratory properly licensed pursuant to Chapter
483 of the Florida Statutes, or a similar
applicable law of another state, where
examinations are performed on materials or
specimens taken from the human body to
provide information or materials used in the
diagnosis, prevention, or treatment of a
Condition.
Independent Diagnostic Testing Facility
means a facility, independent of a Hospital or
Physician's office, which is a fixed location, a
mobile entity, or an individual non - Physician
practitioner where diagnostic tests are
performed by a licensed Physician or by
licensed, certified non - Physician personnel
under appropriate Physician supervision. An
Independent Diagnostic Testing Facility must be
appropriately registered with the Agency for
Health Care Administration and must comply
with all applicable Florida law or laws of the
State in which it operates. Further, such an
entity must meet BCBSF's criteria for eligibility
as an Independent Diagnostic Testing Facility.
In- Network means, when used in reference to
Covered Services, the level of benefits payable
to an In- Network Provider as designated on the
Schedule of Benefits under the heading "In-
Network". Otherwise, In- Network means, when
used in reference to a Provider, that, at the time
Covered Services are rendered, the Provider is
an In- Network Provider under the terms of this
Booklet.
In- Network Provider means any health care
Provider who, at the time Covered Services
were rendered to you, was under contract with
BCBSF to participate in BCBSF's NetworkBlue
and included in the panel of providers
designated by BCBSF as "In- Network" for your
specific plan. (Please refer to your Schedule of
Benefits). For payment purposes under this
Benefit Booklet only, the term In- Network
Provider also refers, when applicable, to any
health care Provider located outside the state of
Florida who or which, at the time Health Care
Services were rendered to you, participated as a
BlueCard (Out -of- State) PPO Program Provider
under the Blue Cross Blue Shield Association's
BlueCard (Out -of- State) Program.
Intensive Outpatient Treatment means
treatment in which an individual receives at least
3 clinical hours of institutional care per day (24-
hour period) for at least 3 days a week and
Definitions 20 -10
returns home or is not treated as an inpatient
during the remainder of that 24 -hour period. A
Hospital shall not be considered a "home" for
purposes of this definition.
In Vitro Fertilization (IVF) means a process in
which an egg and sperm are combined in a
laboratory dish to facilitate fertilization. If
fertilized, the resulting embryo is transferred to
the woman's uterus.
Licensed Practical Nurse means a person
properly licensed to practice practical nursing
pursuant to Chapter 464 of the Florida Statues,
or a similar applicable law of another state.
Massage Therapist means a person properly
licensed to practice Massage, pursuant to
Chapter 480 of the Florida Statutes, or a similar
applicable law of another state.
Massage or Massage Therapy means the
manipulation of superficial tissues of the human
body using the hand, foot, arm, or elbow. For
purposes of this Benefit Booklet, the term
Massage or Massage Therapy does not include
the application or use of the following or similar
techniques or items for the purpose of aiding in
the manipulation of superficial tissues: hot or
cold packs; hydrotherapy; colonic irrigation;
thermal therapy; chemical or herbal
preparations; paraffin baths; infrared light;
ultraviolet light; Hubbard tank; or contrast baths.
Mastectomy means the removal of all or part of
the breast for Medically Necessary reasons as
determined by a Physician.
Medical Literature means scientific studies
published in a United States peer- reviewed
national professional journal.
Medical Pharmacy Physician- administered
Prescription Drugs which are rendered in a
Physician's office.
Medically Necessary or Medical Necessity
means that, with respect to a Health Care
Service, a Provider, exercising prudent clinical
judgment, provided, or is proposing or
recommending to provide the Health Care
Service to you for the purpose of preventing,
evaluating, diagnosing or treating an illness,
injury, disease or its symptoms, and that the
Health Care Service was /is:
1. in accordance with Generally Accepted
Standards of Medical Practice;
2. clinically appropriate, in terms of type,
frequency, extent, site of Service, duration,
and considered effective for your illness,
injury, or disease or symptoms;
3. not primarily for your convenience, your
family's convenience, your caregiver's
convenience or that of your Physician or
other health care Provider, and
4. not more costly than the same or similar
Service provided by a different Provider, by
way of a different method of administration,
an alternative location (e.g., office vs.
inpatient), and /or an alternative Service or
sequence of Services at least as likely to
produce equivalent therapeutic or diagnostic
results as to the diagnosis or treatment of
your illness, injury, disease or symptoms.
When determining whether a Service is not
more costly than the same or similar Service as
referenced above, we may, but are not required
to, take into consideration various factors
including, but not limited to, the following:
a. the Allowed Amount for Service at the
location for the delivery of the Service
versus an alternate setting;
b. the amount we have to pay to the
proposed particular Provider versus the
Allowed Amount for a Service by
another Provider including Providers of
the same and /or different licensure
and /or specialty; and /or,
c. an analysis of the therapeutic and /or
diagnostic outcomes of an alternate
Definitions 20 -11
treatment versus the recommended or
performed procedure including a
comparison to no treatment. Any such
analysis may include the short and /or
long -term health outcomes of the
recommended or performed treatment
versus alternate treatments including an
analysis of such outcomes as the ability
of the proposed procedure to treat
comorbidities, time to disease
recurrence, the likelihood of additional
Services in the future, etc.
Note: The distance you have to travel to receive
a Health Care Service, time off from work,
overall recovery time, etc. are not factors that we
are required to consider when evaluating
whether or not a Health Care Service is not
more costly than an alternative Service or
sequence of Services.
Reviews we perform of Medical Necessity may
be based on comparative effectiveness
research, where available, or on evidence
showing lack of superiority of a particular
Service or lack of difference in outcomes with
respect to a particular Service. In performing
Medical Necessity reviews, we may take into
consideration and use cost data which may be
proprietary.
It is important to remember that any review of
Medical Necessity by us is solely for the purpose
of determining coverage or benefits under this
Booklet and not for the purpose of
recommending or providing medical care. In this
respect, we may review specific medical facts or
information pertaining to you. Any such review,
however, is strictly for the purpose of
determining, among other things, whether a
Service provided or proposed meets the
definition of Medical Necessity in this Booklet as
determined by us. In applying the definition of
Medical Necessity in this Booklet, we may apply
our coverage and payment guidelines then in
effect. You are free to obtain a Service even if
we deny coverage because the Service is not
Medically Necessary; however, you will be solely
responsible for paying for the Service.
Medicare means the federal health insurance
provided under Title XVIII of the Social Security
Act and all amendments thereto.
Medication Guide for the purpose of this
Benefit Booklet means the guide then in effect
issued by us where you may find information
about Specialty Drugs, Prescription Drugs that
require prior coverage authorization and Self -
Administered Prescription Drugs that may be
covered under this plan.
Note: The Medication Guide is subject to
change at any time. Please refer to our website
at www.floridablue.com for the most current
guide or you may call the customer service
phone number on your Identification Card for
current information.
Mental Health Professional means a person
properly licensed to provide mental health
Services, pursuant to Chapter 491 of the Florida
Statutes, or a similar applicable law of another
state. This professional may be a clinical social
worker, mental health counselor or marriage and
family therapist. A Mental Health Professional
does not include members of any religious
denomination who provide counseling services.
Mental and Nervous Disorder means any
disorder listed in the diagnostic categories of the
International Classification of Disease (ICD -9
CM or ICD 10 CM), or their equivalents in the
most recently published version of the American
Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders,
regardless of the underlying cause, or effect, of
the disorder.
Midwife means a person properly licensed to
practice midwifery pursuant to Chapter 467 of
the Florida Statutes, or a similar applicable law
of another state.
NetworkBlue means, or refers to, the preferred
provider network established and so designated
by BCBSF which is available to individuals
covered under this Benefit Booklet. Please note
Definitions 20 -12
that BCBSF's Preferred Patient Care (PPC)
preferred provider network is not available to
individuals covered under this Benefit Booklet
Occupational Therapist means a person
properly licensed to practice Occupational
Therapy pursuant to Chapter 468 of the Florida
Statutes, or a similar applicable law of another
state.
Occupational Therapy means a treatment that
follows an illness or injury and is designed to
help a patient learn to use a newly restored or
previously impaired function.
Orthotic Device means any rigid or semi -rigid
device needed to support a weak or deformed
body part or restrict or eliminate body
movement.
Out -of- Network means, when used in reference
to Covered Services, the level of benefits
payable to an Out -of- Network Provider as
designated on the Schedule of Benefits under
the heading "Out -of- Network ". Otherwise, Out -
of- Network means, when used in reference to a
Provider, that, at the time Covered Services are
rendered, the Provider is not an In- Network
Provider under the terms of this Booklet.
Out -of- Network Provider means a Provider
who, at the time Health Care Services were
rendered:
1. did not have a contract with us to participate
in NetworkBlue but was participating in our
Traditional Program; or
2. did not have a contract with a Host Blue to
participate in its local PPO Program for
purposes of the BlueCard (Out -of- State)
PPO Program but was participating, for
purposes of the BlueCard (Out -of- State)
Program, as a BlueCard (Out -of- State)
Traditional Program Provider; or
3. did have a contract to participate in
NetworkBlue but was not included in the
panel of Providers designated by us to be
In- Network for your Plan; or
4. did not have a contract with us to participate
in NetworkBlue or our Traditional Program;
or
5. did not have a contract with a Host Blue to
participate for purposes of the BlueCard
(Out -of- State) Program as a BlueCard (Out -
of State) Traditional Program Provider.
Outpatient Rehabilitation Facility means an
entity which renders, through providers properly
licensed pursuant to Florida law or the similar
law or laws of another state: outpatient physical
therapy; outpatient speech therapy; outpatient
occupational therapy; outpatient cardiac
rehabilitation therapy; and outpatient Massage
for the primary purpose of restoring or improving
a bodily function impaired or eliminated by a
Condition. Further, such an entity must meet
BCBSF's criteria for eligibility as an Outpatient
Rehabilitation Facility. The term Outpatient
Rehabilitation Facility, as used herein, shall not
include any Hospital including a general acute
care Hospital, or any separately organized unit
of a Hospital, which provides comprehensive
medical rehabilitation inpatient services, or
rehabilitation outpatient services, including, but
not limited to, a Class III "specialty rehabilitation
hospital" described in Chapter 59A, Florida
Administrative Code or the similar law or laws of
another state.
Pain Management includes, but is not limited
to, Services for pain assessment, medication,
physical therapy, biofeedback, and /or
counseling. Pain rehabilitation programs are
programs featuring multidisciplinary Services
directed toward helping those with chronic pain
to reduce or limit their pain.
Partial Hospitalization means treatment in
which an individual receives at least 6 clinical
hours of institutional care per day (24 -hour
period) for at least 5 days per week and returns
home or is not treated as an inpatient during the
remainder of that 24 -hour period. A Hospital
shall not be considered a "home" for purposes of
this definition.
Definitions 20 -13
Physical Therapy means the treatment of
disease or injury by physical or mechanical
means as defined in Chapter 486 of the Florida
Statutes or a similar applicable law of another
state. Such therapy may include traction, active
or passive exercises, or heat therapy.
Physical Therapist means a person properly
licensed to practice Physical Therapy pursuant
to Chapter 486 of the Florida Statutes, or a
similar applicable law of another state.
Physician means any individual who is properly
licensed by the state of Florida, or a similar
applicable law of another state, as a Doctor of
Medicine (M.D.), Doctor of Osteopathy (D.O.),
Doctor of Podiatry (D.P.M.), Doctor of
Chiropractic (D.C.), Doctor of Dental Surgery or
Dental Medicine (D.D.S. or D.M.D.), or Doctor of
Optometry (O.D.).
Physician Assistant means a person properly
licensed pursuant to Chapter 458 of the Florida
Statutes, or a similar applicable law of another
state.
Physician Specialty Society means a United
States medical specialty society that represents
diplomates certified by a board recognized by
the American Board of Medical Specialties.
Post - Service Claim means any paper or
electronic request or application for coverage,
benefits, or payment for a Service actually
provided to you (not just proposed or
recommended) that is received by us on a
properly completed claim form or electronic
format acceptable to us in accordance with the
provisions of this section.
Pre - Service Claim means any request or
application for coverage or benefits for a Service
that has not yet been provided to you and with
respect to which the terms of the Benefit Booklet
condition payment for the Service (in whole or in
part) on approval by us of coverage or benefits
for the Service before you receive it. A Pre -
Service Claim may be a Claim Involving Urgent
Care. As defined herein, a Pre - Service Claim
shall not include a request for a decision or
opinion by us regarding coverage, benefits, or
payment for a Service that has not actually been
rendered to you if the terms of the Benefit
Booklet do not require (or condition payment
upon) approval by us of coverage or benefits for
the Service before it is received.
Prescription Drug means any medicinal
substance, remedy, vaccine, biological product,
drug, pharmaceutical or chemical compound
which can only be dispensed with a Prescription
and /or which is required by state law to bear the
following statement or similar statement on the
label: "Caution: Federal law prohibits
dispensing without a Prescription ".
Preventive Services Guide means the guide
then in effect issued by us that contains a listing
of Preventive Health Services covered under
your plan. Note: The Preventive Services
Guide is subject to change Please refer to our
website at
www. FloridaBlue.com /heaIthresources for the
most current guide.
Prosthetist/Orthotist means a person or entity
that is properly licensed, if applicable, under
Florida law, or a similar applicable law of
another state, to provide services consisting of
the design and fabrication of medical devices
such as braces, splints, and artificial limbs
prescribed by a Physician.
Prosthetic Device means a device which
replaces all or part of a body part or an internal
body organ or replaces all or part of the
functions of a permanently inoperative or
malfunctioning body part or organ.
Provider means any facility, person or entity
recognized for payment by BCBSF under this
Booklet.
Provider Incentive means an additional amount
of compensation paid to a health care Provider
by a Blue Cross and /or Blue Shield Plan, based
on the Provider's compliance with agreed -upon
Definitions 20 -14
procedural and /or outcome measures for a
particular population of covered persons.
Psychiatric Facility means a facility properly
licensed under Florida law, or a similar
applicable law of another state, to provide for the
Medically Necessary care and treatment of
Mental and Nervous Disorders. For purposes of
this Booklet, a psychiatric facility is not a
Hospital or a Substance Abuse Facility, as
defined herein.
Psychologist means a person properly licensed
to practice psychology pursuant to Chapter 490
of the Florida Statutes, or a similar applicable
law of another state.
Registered Nurse means a person properly
licensed to practice professional nursing
pursuant to Chapter 464 of the Florida Statutes,
or a similar applicable law of another state.
Registered Nurse First Assistant (RNFA)
means a person properly licensed to perform
surgical first assisting services pursuant to
Chapter 464 of the Florida Statutes or a similar
applicable law of another state.
Rehabilitation Services means Services for the
purpose of restoring function lost due to illness,
injury or surgical procedures including but not
limited to cardiac rehabilitation, pulmonary
rehabilitation, Occupational Therapy, Speech
Therapy, Physical Therapy and Massage
Therapy.
Rehabilitative Therapies means therapies the
primary purpose of which is to restore or
improve bodily or mental functions impaired or
eliminated by a Condition, and include, but are
not limited to, Physical Therapy, Speech
Therapy, Pain Management, pulmonary therapy
or Cardiac Therapy.
Residential Treatment Facility means a facility
properly licensed under Florida law or a similar
applicable law of another state, to provide care
and treatment of Mental and Nervous Disorders
and Substance Dependency and meets all of the
following requirements:
• Has Mental Health Professionals on -site 24
hours per day and 7 days per week;
• Provides access to necessary medical
services 24 hours per day and 7 days per
week;
• Provides access to at least weekly sessions
with a behavioral health professional fully
licensed for independent practice for
individual psychotherapy;
• Has individualized active treatment plan
directed toward the alleviation of the
impairment that caused the admission;
• Provides a level of skilled intervention
consistent with patient risk;
• Is not a wilderness treatment program or
any such related or similar program, school
and /or education service.
With regard to Substance Dependency
treatment, in addition to the above, must meet
the following:
• If Detoxification Services are necessary,
provides access to necessary on -site
medical services 24 hours per day and 7
days per week, which must be actively
supervised by an attending physician;
• Ability to assess and recognize withdrawal
complications that threaten life or bodily
function and to obtain needed Services
either on site or externally;
• Is supervised by an on -site Physician 24
hours per day and 7 days per week with
evidence of close and frequent observation
Residential Treatment Services means
treatment in which an individual is admitted by a
Physician overnight to a Hospital, Psychiatric
Hospital or Residential Treatment Facility and
receives daily face to face treatment by a Mental
Health Professional for at least 8 hours per day,
Definitions 20 -15
each day. The Physician must perform the
admission evaluation with documentation and
treatment orders within 48 hours and provide
evaluations at least weekly with documentation.
A multidisciplinary treatment plan must be
developed within 3 days of admission and must
be updated weekly.
Self- Administered Prescription Drug means
an FDA - approved Prescription Drug that you
may administer to yourself, as recommended by
a Physician.
Skilled Nursing Facility means an institution or
part thereof which meets BCBSF's criteria for
eligibility as a Skilled Nursing Facility and which:
1) is licensed as a Skilled Nursing Facility by the
state of Florida or a similar applicable law of
another state; and 2) is accredited as a Skilled
Nursing Facility by the Joint Commission on
Accreditation of Healthcare Organizations or
recognized as a Skilled Nursing Facility by the
Secretary of Health and Human Services of the
United States under Medicare, unless such
accreditation or recognition requirement has
been waived by BCBSF.
Sound Natural Teeth means teeth that are
whole or properly restored (restoration with
amalgams, resin or composite only); are without
impairment, periodontal, or other conditions; and
are not in need of Services provided for any
reason other than an Accidental Dental Injury.
Teeth previously restored with a crown, inlay,
onlay, or porcelain restoration, or treated with
endodontics, are not Sound Natural Teeth.
Specialty Drug means an FDA - approved
Prescription Drug that has been designated,
solely by us, as a Specialty Drug due to special
handling, storage, training, distribution
requirements and /or management of therapy.
Specialty Drugs may be Provider administered
or self- administered and are identified with a
special symbol in the Medication Guide.
Specialty Pharmacy means a Pharmacy that
has signed a Participating Pharmacy Provider
Agreement with us to provide specific
Prescription Drug products, as determined by
us. In- Network Specialty Pharmacies are listed
in the Medication Guide.
Speech Therapy means the treatment of
speech and language disorders by a Speech
Therapist including language assessment and
language restorative therapy services.
Speech Therapist means a person properly
licensed to practice Speech Therapy pursuant to
Chapter 468 of the Florida Statutes, or a similar
applicable law of another state.
Stabilize means, with respect to an emergency
medical condition described above, to provide
such medical treatment of the condition as may
be necessary to assure, within reasonable
medical probability, that no material deterioration
of the condition is likely to result from or occur
during.
1) A the transfer of the individual from a facility;
or,
2) with respect to an emergency medical
condition as described above.
Standard Reference Compendium means:
1) the United States Pharmacopoeia Drug
Information; 2) the American Medical
Association Drug Evaluation; or 3) the American
Hospital Formulary Service Hospital Drug
Information.
Substance Abuse Facility means a facility
properly licensed under Florida law, or a similar
applicable law of another state, to provide
necessary care and treatment for Substance
Dependency. For the purposes of this Booklet a
Substance Abuse Facility is not a Hospital or a
Psychiatric Facility, as defined herein.
Substance Dependency means a Condition
where a person's alcohol or drug use injures his
or her health; interferes with his or her social or
economic functioning; or causes the individual to
lose self - control.
Definitions 20 -16
Traditional Program means, or refers to,
BCBSF`s provider contracting programs called
Payment for Physician Services (PPS) and
Payment for Hospital Services (PHS). For
purposes of this Benefit Booklet, the term
Traditional Program also refers, when
applicable, to the traditional Provider contracting
programs of other Blue Cross and /or Blue Shield
organizations as designated under the Blue
Cross and Blue Shield Association's BlueCard
Program.
Traditional Program Providers means, or
refers to, those health care Providers who are
not NetworkBlue Providers, but who, or which, at
the time you received Services from them were
participating in the Traditional Program. For
purposes of payment under this Benefit Booklet
only, the term Traditional Program Provider also
refers, when applicable, to any health care
Provider located outside the state of Florida who
or which, at the time Health Care Services were
rendered to you, participated as a BlueCard
Traditional Provider under the Blue Cross and
Blue Shield Association's BlueCard Program
Traditional Program Providers are considered
out of network for benefit calculation purposes;
however, does not balance bill the member.
Urgent Care Center means a facility properly
licensed that: 1) is available to provide Services
to patients at least 60 hours per week with at
least twenty -five (25) of those available hours
after 5:00 p.m. on weekdays or on Saturday or
Sunday; 2) posts instructions for individuals
seeking Health Care Services, in a conspicuous
public place, as to where to obtain such
Services when the Urgent Care Center is
closed; 3) employs or contracts with at least one
or more Board Certified or Board Eligible
Physicians and Registered Nurses (RNs) who
are physically present during all hours of
operation. Physicians, RNs, and other medical
professional staff must have appropriate training
and skills for the care of adults and children; and
4) maintains and operates basic diagnostic
radiology and laboratory equipment in
compliance with applicable state and /or federal
laws and regulations.
For 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.
Value -Based Program means an outcomes -
based payment arrangement and /or a
coordinated care model facilitated with one or
more local Providers that is evaluated against
cost and quality metrics /factors and is reflected
in Provider payment.
Waiting Period means the length of time
established by Monroe County BOCC which
must be met by an individual before that
individual becomes eligible for coverage under
this Benefit Booklet.
Zygote Intrafallopian Transfer (ZIFT) means a
process in which an egg is fertilized in the
laboratory and the resulting zygote is transferred
to the fallopian tube at the pronuclear stage
(before cell division takes place). The eggs are
retrieved and fertilized on one day and the
zygote is transferred the following day.
Definitions 20 -17
7. transfusion supplies and equipment;
8. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG);
9. chemotherapy treatment for proven
malignant disease; and
10. Physical, Speech, and Occupational
Therapies;
A treatment plan from your Physician may be
required in order to determine coverage and
payment.
Exclusion:
Expenses for an inpatient admission to a Skilled
Nursing Facility for purposes of Custodial Care,
convalescent care, or any other Service
primarily for the convenience of you and /or your
family members or the Provider are excluded.
Surgical Assistant Services
Services rendered by a Physician, Registered
Nurse First Assistant or Physician Assistant
when acting as a surgical assistant (provided no
intern, resident, or other staff physician is
available) when the assistant is necessary are
covered.
Surgical Procedures
Surgical procedures performed by a Physician
may be covered including the following:
sterilization (tubal ligations and
vasectomies), regardless of Medical
Necessity;
2. surgery to correct deformity which was
caused by disease, trauma, birth defects,
growth defects or prior therapeutic
processes;
3. oral surgical procedures for excisions of
tumors, cysts, abscesses, and lesions of the
mouth;
4. surgical procedures involving bones orjoints
of the jaw (e.g., temporomandibular joint
[TMJ]) and facial region if, under accepted
medical standards, such surgery is
necessary to treat Conditions caused by
congenital or developmental deformity,
disease, or injury;
5. Services of a Physician for the purpose of
rendering a second surgical opinion and
related diagnostic services to help determine
the need for surgery; and
6. Gender reassignment surgery and Services
related to gender dysphoria or gender
transition are covered.
Exclusions:
The following Services, which are
considered cosmetic in nature, are not
covered when used to improve the gender -
specific appearance of an individual.
Examples of Services which are considered
cosmetic include, but are not limited to:
a. reduction thyroid chondroplasty;
b. liposuction;
c. rhinoplasty;
d. facial bone reconstruction;
e. face lift;
f. blepharoplasty;
g. voice modification surgery;
h. hair removal /hairplasty; or
i. breast augmentation.
7. Surgical procedures performed on a Covered
Plan Participant for the treatment of Morbid
Obesity (e.g., intestinal bypass, stomach
stapling, balloon dilation) and the associated
care provided the Covered Plan Participant
has not previously undergone the same or
similar procedure in the lifetime of this
Group Health Plan when medically
necessary.
Exclusion: