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Item C36
County off Monroe ELj »moo � i G�, � BOARD OF COUNTY COMMISSIONERS /� ri � �� Mayor George Neugent, District 2 The Florida. Ke Sew', y i Mayor Pro Tern David Rice, District 4 ; -== :'„ j y Danny L. Kolhage, District I Heather Carruthers, District 3 Sylvia J. Murphy, District 5 County Commission Meeting May 17, 2017 Agenda Item Number: C.36 Agenda Item Summary #2957 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez -Gonzalez (305) 292-4448 No AGENDA ITEM WORDING: Approval to advertise a solicitation for proposals for Medical and Prescription Drug (RX) Stop Loss Insurance. ITEM BACKGROUND: The County's health plan has experienced significant increases in the cost of health care and prescription coverage over the past several years. In 2015 the plan had 43 individuals with annual claims in excess of $50K. These 43 individuals cost the plan $5,349,407 (excluding RX). The highest cost claim was $560,607 for an individual. In 2016 the plan had 50 individuals with claims in excess of $50K. These individuals cost the plan $6,287,104 (excluding RX). The highest cost claim was $816,734 for an individual. The BOCC directed staff to issue an RFP in 2017 for Medical & RX Stop Loss Insurance. Previously, Gallagher Benefits analyzed Stop Loss insurance and the BOCC elected not to pursue stop loss as long as we were able to keep a 6 month reserve balance in the Health Fund. PREVIOUS RELEVANT BOCC ACTION: The County dropped its Stop Loss Coverage on 10/01/2001 after a reinsurance analysis was done over the previous 10 years and there was only one year where the County would have received reimbursements enough to cover premium. Stop Loss Insurance was bid in 2011 as part of an RFP that included Fully & Self Insured, Pharmacy Benefit Managers. Recommendation from consultant and staff was not to purchase Stop Loss at this time. May 1, 2014 an agenda item was presented to the Board requesting approval to advertise a solicitation for proposals for Medical Stop Loss Insurance. After discussion a motion was made not to approve solicitation for proposals. Motion passed unanimously. CONTRACT/AGREEMENT CHANGES: n/a STAFF RECOMMENDATION: Approval DOCUMENTATION: MCBCC 2017 STOP LOSS RFP EXHIBIT A - SCOPE OF SERVICES EXHIBIT B - STOP LOSS QUESTIONNAIRE EXHIBIT C - STOP LOSS PRICING FORM ATTACHMENT A - CENSUS ATTACHMENT B CLAIMS EXPERIENCE 5.3.17.2.pdf (MINUTETRAQ) ATTACHMENT C - BENEFIT BOOKLET ATTACHMENT E - SUPPLEMENTAL TO BENEFIT BOOKLET 2017 ATTACHMENT D - MEDICAL LAG REPORT FINANCIAL IMPACT: Effective Date: Unknown Expiration Date: Unknown Total Dollar Value of Contract: Unknown Total Cost to County: Unknown Current Year Portion: Budgeted: NO Source of Funds: Primarily ad valorem CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: No Grant: County Match: Insurance Required: Additional Details: N/A If yes, amount: REVIEWED BY: Christine Hurley Completed 05/02/2017 8:34 AM Budget and Finance Completed 05/02/2017 2:24 PM Cynthia Hall Completed 05/03/2017 12:40 PM Maria Slavik Completed 05/03/2017 12:58 PM Kathy Peters Completed 05/03/2017 2:24 PM Board of County Commissioners Pending 05/17/2017 9:00 AM MONROE COUNTY REQUEST FOR PROPOSALS FOR MEDICAL AND RX STOP LOSS INSURANCE BOARD OF COUNTY COMMISSIONERS Mayor, George Neugent, District 2 Mayor Pro Tem, David Rice, District 4 Danny L. Kolhage, District 1 Heather Carruthers, District 3 Sylvia J. Murphy, District 5 COUNTY ADMINISTRATOR Roman Gastesi CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES Kevin Madok Employee Benefits May 22, 2017 1 of 29 NOTICE OF REQUEST FOR COMPETITIVE SOLICITATIONS NOTICE IS HEREBY GIVEN that on July 5, 2017, at 3:00 P.M., the Monroe County Purchasing Office will receive and open sealed responses for the following: MEDICAL AND RX STOP LOSS INSURANCE MONROE COUNTY, FLORIDA Requirements for submission and the selection criteria may be requested from DemandStar by Onvia at www.demandstar.com OR www.monroecountybids.com or call toll -free at 1-800-711-1712. The Public Record is available at the Monroe County Purchasing Office located at The Gato Building, 1100 Simonton Street, Room 2-213, Key West, Florida. All Responses must be sealed and must be submitted to the Monroe County Purchasing Office. Publication dates Citizen Wed. 5/10/17 Keynoter Wed. 5/10/17 Reporter Fri. 5/12/17 2 of 29 TABLE OF CONTENTS SECTION ONE - INSTRUCTIONS TO PROPOSERS SECTION TWO - COUNTY FORMS EXHIBITS ATTACHMENTS EXHIBIT A SCOPE OF SERVICES EXHIBIT B STOP LOSS QUESTIONNAIRE EXHIBIT C STOP LOSS PRICING FORM A. CENSUS B. CLAIMS EXPERIENCE C. BENEFIT BOOKLET D. MEDICAL LAG REPORT E. SUPPLEMENT TO THE PLAN 2017 3 of 29 SECTION ONE: INSTRUCTIONS TO PROPOSERS 1. Objective of the Request for Proposals (RFP) The County is seeking an insurance vendor to provide the County with a stop loss insurance policy for its self -insured health plan in accordance with the specifications outlined in this Request for Proposals. The County anticipates that this contract will be awarded for an effective date of January 1, 2018. The initial policy term will be for one year and the County may elect to renew for up to three (3) additional consecutive 1 year terms, dependent upon acceptability of cost, coverage, service, provider stability and market conditions. The County is requesting proposals for Specific and Aggregate insurance as follows Deductible $300,000 $500,000 $750,000 Contract Both 15/12 and Paid Lifetime Max: Unlimited Agg. Corridor 125% Annual Agg Max: Unlimited Requested Commission None The County may elect to purchase only Specific Stop Loss coverage. Please indicate in Exhibit C, the Stop Loss Pricing Form, whether there is an impact to your rates if the Aggregate coverage is not elected. Proposals are requested to be submitted net of commissions, although it is not required If any compensation for an agent is included in the rates, this must be fully disclosed along with the exact services the agent will be providing to the County. Please note that any entity and/or person who participated in the drafting of this RFP is disqualified from submitting a proposal in response to this RFP or receiving a commission as a result of the award of a contract for services arising out of this RFP. Calendar Date Activity May 22, 2017 RFP Release Date June 12, 2017 Deadline for Vendor Questions June 19, 2017 Addendum Release Date July 5, 2017 Bid Opening — 3:00 PM. No late bids will be accepted September 13, 2017 Selection Committee Ranking Meeting September 22 2017 Finalist Interviews (if necessary) October 18, 2017 Monroe County BOCC Meeting — Approval to negotiate contract January 1, 2018 Contract Effective Date NOTICE OF POSSIBLE INTERVIEW 4 of 29 The County may wish to interview finalists in Key West on September 22, 2017. Proposers who are to be invited for finalist interviews will be notified no later than September 13, 2017 (specific instructions regarding the presentation will also be provided no later than September 13, 2017) and should be committed to accommodating this time frame to meet in Key West. Staff present should include all key staff with direct client responsibilities for the MCBCC account, as well as an individual who is authorized to contractually obligate the firm. 2. Background Information Monroe County is a non -charter county and a political subdivision of the State of Florida. The County population is approximately 76,000. The Board of County Commissioners, constituted as the governing body, has all the powers of a body corporate, including the powers to contract; to sue and be sued; to acquire, purchase, hold, lease and convey real estate and personal property; to borrow money and to generally exercise the powers of a public authority organized and existing for the purpose of providing community services to citizens within its territorial boundaries. In order to carry out this function, the County is empowered to levy taxes to pay the cost of operations. Monroe County is the southernmost county in the United States. It is comprised of the Florida Keys and a portion of the Florida Everglades. The Florida Keys are an archipelago of islands stretching from Key West, only 90 miles from Cuba, up to the mainland. In addition to the unincorporated county, there are five municipalities in the Florida Keys: Key West, Marathon, Key Colony Beach, Layton, and Islamorada. Further information about the demographics of the County can be found here: http://www.monroecounty-fl.gov/index.aspx?NID=27 . Approximately one-third of the population is situated in the City of Key West, which is the county seat; however, the County offers services throughout the Keys, and has government buildings throughout the Lower Keys (primarily Big Pine Key), Middle Keys (primarily Marathon), and Upper Keys (primarily Plantation Key and Key Largo) in addition to Key West, with employees stationed in all locations. 3. Present Information Monroe County currently offers one self -insured PPO plan to its employees, retirees, and dependents, including surviving spouses. Current Plan benefits are shown in ATTACHMENT C — BENEFIT BOOKLET. The anniversary date for the plan year is January 1. Premiums for active employees may be paid on a pretax basis through the County's Section 125 Plan. Premiums for Retirees and Surviving Spouses are collected by the County. Coverage is currently tracked by Active Employees, Retirees, COBRA, and Surviving Spouses for the following groupings: • The Board of County Commissioners; • The Clerk of the Circuit Court; • Tax Collector; • Property Appraiser; • Supervisor of Elections; • Sheriff's Office; • Land Authority, and; • Court Administration. 5 of 29 Domestic Partners are included as dependents subject to the criteria in Monroe County Resolution 081-1998, available at http-//www.minutes-monroe- clerk.com/webIink8/0/doc/2348/Page1.aspx. The self -insured PPO medical plan is administered by Florida Blue, which has provided coverage since 2011. The Prescription Drug benefit is carved out and is administered by Envision Rx. The County is committed to maintaining strong network access, aggressive cost controls, effective medical management programs, and transparency. Prior to moving to Florida Blue, the PPO plan was administered by Wells Fargo, with Precertification/Utilization Review provided by Keys Physician Hospital alliance (KPHA) Networks were provided at that time through KPHA and the Dimension Health Plus Network in South Florida, with Multiplan as a wrap network. The County has not carried Stop Loss coverage for the Medical Plan since it dropped the coverage in 2001. Compensation: Proposer shall be in compliance with Section 624.428, Florida Statutes. If any commissions and/or service fees are included in your rate quotation, you shall specify the amount of the commissions and/or service fees, to whom they may be paid and your reason(s) for including them. The Monroe Countv Board of Countv Commissioners has enaaaed an indeaendent roaosals to the Selection Committee with reaard to the RFP. and to assist in Please note that any entity and/or person who participated in the drafting of this RFP is disqualified from submitting a proposal in response to this RFP or receiving a commission as a result of the award of a contract for services arising out of this RFP. 6 of 29 4. Evaluation Criteria A Selection Committee will be convened to review the Proposals and recommend which Vendor should be selected for the project. The successful Proposer will be selected based on the following criteria. Cost of Services — pricing 30 points Ability to provide the Scope of Services. The points 30 points for this criterion will be assigned based on both the responses/compliance to the Scope of Services and the overall information included in the Proposal. This criterion will evaluate both quantitative and qualitative information including but not limited to: 1. Acceptance of County Contractual Requirements 2. Adherence to the Florida Local Government Prompt Payment Act, Section 218.70 F.S. 3. Termination clauses in the contract 4. Indemnification language Contractual Assessment analyzing the Proposals for 20 points contract and coverage terms, including but not limited to: 1. Potential Gaps in coverage 2. Adherence to Plan Documents 3. Notice of Loss provisions Prior experience with government clients/references 10 points Compliance with RFP Specifications (responsiveness, 5 points submission of required forms, follows required format, etc.) Location of firm (local preference if applicable: up to 5 5 points additional points) Total points earned are on a scale of 1 —100 points 1 = lowest 100 = highest A Selection Committee will be analyzing the Proposals, reviewing the Analysis, and providing recommendations to the County Administrator who will ultimately make a recommendation to the Board of County Commissioners regarding which Proposer should be hired. 5. Requests for Additional Information or Clarification Requests for additional information or clarification relating to the specifications of this Request for Proposals shall be submitted in writing directly to: Maria Fernandez -Gonzalez, Administrator/HIPAA Privacy Officer 1100 Simonton Street, Suite 2-268 7 of 29 Key West, Florida 33040 Facsimile (305) 292-4452 All requests for additional information for, must be received no later than 3:00 PM, June 12, 2017. Any requests received after that date and time will not be answered. All timely requests for additional information will be answered via an addendum to the RFP, which shall be distributed to all interested Proposers on the schedule listed above. Oral requests will not be answered. All addenda are a part of the contract documents and each Proposer will be bound by such addenda, whether or not received by him/her. It is the responsibility of each Proposer to verify that he/she has received all addenda issued before responses are opened. 6. Content of Submission The Proposal submitted in response to this Request for Proposals (RFP) shall be submitted as instructed in the RFP documents. Proposers are responsible to access and review the County's specifications. The Proposal shall be printed on 8-1/2" x 11" white paper and bound; shall be clear and concise, tabulated, and provide the information requested herein. Statements submitted without the required information will not be considered. The Proposer should not withhold any information from the written response in anticipation of presenting the information orally or in a demonstration, since oral presentations or demonstrations may not be solicited. Each Proposer must submit adequate documentation to certify the Proposer's compliance with the County's requirements. Proposer should focus specifically on the information requested. Responses shall be organized as indicated below. 7. Format. Each Proposal shall include the following: A. Cover Page_ A cover page that states "Request for Proposals for Medical and Rx Stop Loss Insurance". The cover page should contain Proposer's name, address, telephone number, and the name of the Proposer's contact person(s). B. Table of Contents The Table of Contents shall be sufficiently detailed to allow for the members of the Selection Committee to easily locate all the required components of the Proposal. C. Tabbed Sections 8 of 29 Tab 1. Letter of Transmittal The Proposer shall provide a letter confirming that the Proposal is an authorized offer by the Proposer and shall list the names of the persons who will be authorized to make representations for the Proposer, their titles, addresses and telephone numbers. Tab 2. Minimum Qualifications Proposer shall provide a statement addressing each item below and supply evidence in this Tab that demonstrates compliance with the minimum qualifications. • The Proposer shall be licensed in the State of Florida to provide the requested services. • The Proposer shall have an A.M. Best rating of A- or higher and a financial size category of VI or higher. • If the Proposer is not rated by A.M. Best or the A.M. Best rating is below A -/VI, proposer must submit three (3) years of independent audited financial statements. • The Proposer shall provide a minimum of five (5) customer references for which they have provided Stop Loss insurance within the past three (3) years. At least two (2) of these references must be from other city or county governments of a similar size within the State of Florida. Each reference at a minimum shall include: o Name and full address of the client; o Name, address, title, and telephone number of the client contact; o Identification of services provided, including years for which the services were offered • The Proposer shall include at least three (3) letters of reference from clients which describes the services performed and the client's satisfaction with the services provided. Letters of reference are preferred, however, if the Proposer desires to include surveys completed by clients regarding the service of the Proposer, they will be considered. Documents from governmental/public entity clients are preferred. Copies are acceptable. Only those Proposers who provide references along with their Proposal will be awarded points. Tab 3. Scope of Services Please include each of the following completed Exhibits under this Tab 1. EXHIBIT A —Scope of Services. 2. EXHIBIT B — STOP LOSS QUESTIONNAIRE 3. EXHIBIT C — STOP LOSS PRICING FORM. If your response indicates that you "can comply with deviations", you must fully explain the deviations in this Tab. 9 of 29 Tab 4. Staffing for this Project and Qualifications of Key Personnel The Proposer shall briefly describe the composition and structure of the firm (sole proprietorship, corporation, partnership, joint venture) and include names of persons with an interest in the firm. Proposer shall include a list of the proposed staff that will perform the work required and shall identify any sub -contractors that will be used, if awarded this contract. The Proposer shall describe the qualifications for each employee on the project team and identify his/her role on the team. If sub -contractors are to be utilized, Proposer must clearly specify the role of each sub -contractor and provide evidence of their qualifications. Include in this section the location of the main office and the location of the office proposed to work on this project. Tab 5. Litigation In accordance with Section 2-347(h) of the Monroe County Code, the Proposer must provide the following information: (1) A list of the person's or entity's shareholders with five (5) percent or more of the stock or, if a general partnership, a list of the general partners; or, if a limited liability company, a list of its members; or, if a solely owned proprietorship, names(s) of owner(s); (2) A list of the officers and directors of the entity; (3) The number of years the person or entity has been operating and, if different, the number of years it has been providing the services, goods, or construction services called for in the bid specifications (include a list of similar projects); (4) The number of years the person or entity has operated under its present name and any prior names; (5) Answers to the following questions regarding claims and suits: a. Has the person, principals, entity, or any entity previously owned, operated or directed by any of its officers, major shareholders or directors, ever failed to complete work or provide the goods for which it has contracted? If yes, provide details; b. Are there any judgments, claims, arbitration proceeding or suits pending or outstanding against the person, principal of the entity, or entity, or any entity previously owned, operated or directed by any of its officers, directors, or general partners? If yes, provide details; c. Has the person, principal of the entity, entity, or any entity previously owned, operated or directed by any of its officers, major shareholders or directors, within the last five (5) years, been a party to any lawsuit, arbitration, or mediation with regard to a contract for services, goods or construction services similar to those requested in the specifications with private or public entities? If yes, provide details; d. Has the person, principal of the entity, or any entity previously 10 of 29 owned, operated or directed by any of its officers, owners, partners, major shareholders or directors, ever initiated litigation against the county or been sued by the county in connection with a contract to provide services, goods or construction services? If yes, provide details; e. Whether, within the last five (5) years, the owner, an officer, general partner, principal, controlling shareholder or major creditor of the person or entity was an officer, director, general partner, principal, controlling shareholder or major creditor of any other entity that failed to perform services or furnish goods similar to those sought in the request for competitive solicitation. f. Credit references (minimum of three), including name, current address and current telephone number. Tab 6. County Forms Proposer shall complete, execute, and attach the forms specified below which are located in Section Two in this RFP, as well as a copy of a business tax receipt from the Tax Collector's Office and shall include it in this section, i.e. Tab 6: Forms: • Submission Response Form • Lobbying and Conflict of Interest Ethics Clause • Non -Collusion Affidavit • Drug Free Workplace Form • Public Entity Crime Statement • Any Proposer claiming a local preference as defined in Monroe County Ordinance 023-2009 must complete the Local Preference Form and attach to the Proposal. 8. COPIES OF RFP DOCUMENTS A. Only complete sets of RFP Documents will be issued and shall be used in preparing responses. The County does not assume any responsibility for errors or misinterpretations resulting from the use of incomplete sets. B. Complete sets of RFP Documents may be obtained in the manner and at the locations stated in the Notice of Request for Competitive Solicitations. C. Each Proposer is responsible for obtaining all Addenda for this RFP and for acknowledging receipt of all Addenda on the RESPONSE FORM. 9. STATEMENT OF PROPOSAL REQUIREMENTS See also Notice of Request for Competitive Solicitation. Interested firms or individuals are requested to indicate their interest by submitting a total of two (2) signed originals and nine (9) complete copies of the Proposal (total = 11 of 29 11). The Proposer shall also submit two (2) CDs, thumb drives, or other form of electronic media, each of which shall contain a complete electronic copy of the proposal. Proposal Submission All portions of the Proposal must be sent in a sealed envelope, clearly marked on the outside with the Proposer's name and "PROPOSAL FOR MEDICAL AND RX STOP LOSS INSURANCE", addressed to Monroe County Purchasing Department, 1100 Simonton Street, Room 2-213, Key West, FL 33040, which must be received on or before 3.00 P.M. Eastern Daylight Saving Time on July 5, 2017. It is the responsibility of the vendor to send the Proposal in such a way as to ensure delivery by that date and time. The electronic copies must retain all of the Exhibits in the original or requested format (not PDF) in order to be considered compliant with the Bid Specifications. Hand delivered Proposals may request a receipt. No Proposals will be accepted after 3.00 P.M on July 5, 2017. Faxed or e-mailed Proposals shall be automatically rejected. It is the sole responsibility of each Proposer to ensure its Proposal is received in a timely fashion. 10. DISQUALIFICATION OF PROPOSER A. NON -COLLUSION AFFIDAVIT: Any person submitting a proposal in response to this invitation must execute the enclosed NON -COLLUSION AFFIDAVIT. If it is discovered that collusion exists among the Proposers, the proposals of all participants in such collusion shall be rejected, and no participants in such collusion will be considered in future proposals for the same work. B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a proposal on a contract to provide any goods or services to a public entity, may not submit a proposal on a contract with a public entity for the construction or repair of a public building or public work, may not submit Proposals on leases or perform work as a contractor, supplier, subcontractor, or contractor under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. Category Two: $25,000.00 C. DRUG -FREE WORKPLACE FORM: Any person submitting a bid or proposal in response to this invitation must execute the enclosed DRUG - FREE WORKPLACE FORM and submit it with his/her proposal. Failure to complete this form in every detail and submit it with the bid or proposal may result in immediate disqualification of the bid or proposal. 12 of 29 D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any person submitting a bid or proposal in response to this invitation must execute the enclosed LOBBYING AND CONFLICT OF INTEREST CLAUSE and submit it with his/her bid or proposal. Failure to complete this form in every detail and submit it with the bid or proposal may result in immediate disqualification of the bid or proposal. 11. EXAMINATION OF RFP DOCUMENTS A. Each Proposer shall carefully examine the RFP and other contract documents, and inform himself/herself thoroughly regarding any and all conditions and requirements that may in any manner affect cost, progress, or performance of the work to be performed under the contract. Ignorance on the part of the Proposer shall in no way relieve him/her of the obligations and responsibilities assumed under the contract. B. Should a Proposer find discrepancies or ambiguities in, or omissions from, the specifications, or should he be in doubt as to their meaning, he shall at once notify the County. 12. GOVERNING LAWS AND REGULATIONS The Proposer is required to be familiar with and shall be responsible for complying with all federal, state, and local laws, ordinances, rules, professional license requirements and regulations that in any manner affect the work. Knowledge of business tax requirements for Monroe County and municipalities within Monroe County are the responsibility of the Proposer. 13. PREPARATION OF RESPONSES Signature of the Proposer: The Proposer must sign the response forms in the space provided for the signature. If the Proposer is an individual, the words "doing business as or "Sole Owner" must appear beneath such signature. In the case of a partnership, the signature of at least one of the partners must follow the firm name and the words "Member of the Firm" should be written beneath such signature. If the Proposer is a corporation, the title of the officer signing the Response on behalf of the corporation must be stated along with evidence of his authority to sign the Response must be submitted. The Proposer shall state in the response the name and address of each person having an interest in the submitting entity. 14. MODIFICATION OF RESPONSES Written modifications will be accepted from Proposers if addressed to the entity and address indicated in the Notice of Request for Competitive Solicitation and received prior to Proposal due date and time. Modifications must be submitted in a sealed envelope clearly marked on the outside, with the Proposer's name and "MODIFICATION TO MEDICAL AND RX STOP LOSS INSURANCE." If sent by mail or by courier, the above -mentioned envelope shall be enclosed in another envelope addressed to the entity and address stated in the Notice of Request for Proposals. Faxed or e-mailed modifications shall be automatically rejected. 13 of 29 15. RESPONSIBILITY FOR RESPONSE The Proposer is solely responsible for all costs of preparing and submitting the response, regardless of whether a contract award is made by the County. 16. RECEIPT AND OPENING OF RESPONSES Responses will be received until the designated time and will be publicly opened Proposers' names shall be read aloud at the appointed time and place stated in the Notice of Request for Competitive Solicitation. Monroe County's representative authorized to open the responses will decide when the specified time has arrived and no responses received thereafter will be considered. No responsibility will be attached to anyone for the premature opening of a response not properly addressed and identified. Proposers or their authorized agents are invited to be present. The County reserves the right to reject any and all responses and to waive technical error and irregularities as may be deemed best for the interests of the County. The County also reserves the right to withdraw the Request for Competitive Solicitation at any time without an award. Responses that contain modifications that are incomplete, unbalanced, conditional, obscure, or that contain additions not requested or irregularities of any kind, or that do not comply in every respect with the Instruction to Proposer, may be rejected at the option of the County. 17. PROPRIETARY AND CONFIDENTIAL INFORMATION All Proposals received as a result of this RFP are subject to Chapter 119, Florida Statutes and will be made available for inspection by any person in accordance with Florida Statutes. Any Proposer asserting that any portion of its Proposal is confidential or exempt from disclosure under Florida's public records laws must specifically identify the portions of the Proposal asserted to be confidential or exempt and must provide specific citations of the Florida Statutes that establish the confidentiality or exemption. All material that is designated as confidential or exempt from Chapter 119 must be submitted in a separate envelope, clearly identified as "PUBLIC RECORDS EXEMPT" with your name and the Proposer's name marked on the outside. If that material is requested through a public records request, the County will notify the Proposer of the request and give the Proposer five (5) calendar days to obtain a court order blocking the production of the material. If court order is not issued during that time to block the production, the material will be produced. By your designation of material in your Proposal as "Public Records Exempt", you agree to defend and hold harmless the County from any claims, judgments, damages, costs, and attorney's fees and costs of the challenger and for costs and attorney's fees incurred by the County by reason of any legal action challenging your designation. Please be advised that the designation of an item as exempt from disclosure as a Public Record may impact the ability of the Evaluating Body to adequately assess a Proposal and may therefore affect the ultimate award of the contract. 14 of 29 18. AWARD OF CONTRACT A. The County reserves the right to award separate contracts for the services based on geographic area or other criteria, and to waive any informality in any response, or to re -advertise for all or part of the work contemplated. B. The County also reserves the right to reject the response of a Proposer who has previously failed to perform properly or to complete contracts of a similar nature on time. C. The recommendation of the Selection Committee and staff shall be presented to the Board of County Commissioners of Monroe County, Florida, for final selection and award of contract. 19. CERTIFICATE OF INSURANCE AND INSURANCE REQUIREMENTS The Proposer shall be responsible for all necessary insurance coverage as indicated below. Certificates of Insurance must be provided to Monroe County within fifteen (15) days after award of contract, with Monroe County BOCC listed as additional insured as indicated. If the proper insurance forms are not received within the fifteen (15) day period, the contract may be awarded to the next selected Proposer. Policies shall be written by companies licensed to do business in the State of Florida and having an agent for service of process in the State of Florida. Companies shall have an A.M. Best rating of VI or better, The required insurance shall be maintained at all times while Proposer is providing service to County. Worker's Compensation Statutory Limits Employers' Liability Insurance Bodily Injury by Accident $100,000 Bodily Injury by Disease, policy limits $500,000 Bodily Injury by Disease, each employee $100,000 General Liability, including Premises Operation Products and Completed Operations Blanket Contractual Liability Personal Injury Liability Expanded Definition of Property Damage $300,000 Combined Single Limit If split limits are provided, the minimum limits acceptable shall be: $200,000 per person $300,000 per occurrence $200,000 property damage 15 of 29 Professional Liability $1,000,000 per Occurrence $2,000,000 Aggregate Monroe County shall be named as an Additional Insured on the General Liability 20. INDEMNIFICATION The Proposer to whom a contract is awarded shall defend, indemnify and hold harmless the County as outlined below. The Proposer covenants and agrees to indemnify, hold harmless and defend Monroe County, its commissioners, officers, employees, agents and servants from any and all claims for bodily injury, including death, personal injury, and property damage, including damage to property owned by Monroe County, and any other losses, damages, and expenses of any kind, including attorney's fees, court costs and expenses, which arise out of, in connection with, or by reason of services provided by the Proposer or any of its Subcontractor(s), occasioned by the negligence, errors, or other wrongful act or omission of the Proposer, its Subcontractor(s), their officers, employees, servants or agents. In the event that the service is delayed or suspended as a result of the Proposer/Vendor's failure to purchase or maintain the required insurance, the Vendor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Proposer is consideration for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 21. EXECUTION OF CONTRACT The County intends to make an award to the Proposer that has complied with the terms, conditions and requirements of the RFP. Any agreement resulting from this RFP must be governed by the laws of the State of Florida, and must have venue established in the State of Florida. The agreement will be submitted to the Monroe County Board of County Commissioners for final approval. 16 of 29 SECTION TWO: COUNTY FORMS AND INSURANCE FORMS [This page intentionally left blank, with forms to follow.] 17 of 29 RESPONSE FORM RESPOND TO: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Purchasing Department GATO BUILDING, ROOM 2-213 1100 SIMONTON STREET KEY WEST, FLORIDA 33040 ❑I acknowledge receipt of Addenda No.(s) I have included: • Response Form ❑ • Lobbying and Conflict of Interest Clause ❑ • Non -Collusion Affidavit ❑ • Drug Free Workplace Form ❑ • Public Entity Crime Statement ❑ • Copy of business tax receipt from the ❑ Tax Collector's office • Local Preference Form (if applicable) ❑ El have included a current copy of the following professional licenses and proof of business tax: If the applicant is not an individual (sole proprietor), please supply the following information: APPLICANT ORGANIZATION: (Registered business name must appear exactly as it appears on www.sunbiz.org). Any applicant other than an individual (sole proprietor) must submit a printout of the "Detail by Entity Name" screen from Sunbiz, and a copy of the most recent annual report filed with the Florida Department of State, Division of Corporations. Provide your estimated premium below using a 15/12 contract basis Estimated Individual Stop Loss Annual Premium ($300,000): $ Estimated Aggregate Stop Loss Premium (Unlimited with $300,000 ISL): $ Estimated Annual Claims: $ Aggregate Corridor Proposed: % Mailing Address Signed (Print Name) (Title) STATE OF: COUNTY OF: Telephone: _ Fax: Date Witness: Subscribed and sworn to (or affirmed) before me on (date) by to me or has produced identification. (name of affiant). He/She is personally known (type of identification) as NOTARY PUBLIC My Commission Expires: 18 of 29 LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO. 010-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE it (Company) "...warrants that he/it has not employed, retained or otherwise had act on his/her behalf any former County officer or employee in violation of Section 2 of Ordinance No. 010- 1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010- 1990. For breach or violation of this provision the County may, in its discretion, terminate this Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee." (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by personally known to me or has produced (type of identification) as identification (name of affiant). He/She is NOTARY PUBLIC My Commission Expires: 19 of 29 NON -COLLUSION AFFIDAVIT I, of the city of law on my oath, and under penalty of perjury, depose and say that lam of making the Proposal for the project described for the said proposal with full authority to do so; according to of the firm the bidder in the Request for Proposals and that I executed 2. The prices in this bid have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition; 5. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by known to me or has produced as identification. (name of affiant). He/She is personally (type of identification) NOTARY PUBLIC My Commission Expires: 20 of 29 DRUG -FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that: (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug -free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on produced (Signature) Date: (date) by (name of affiant). He/She is personally known to me or has (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 21 of 29 PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." I have read the above and state that neither (Proposer's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by known to me or has produced (type of identification) as identification. (name of affiant). He/She is personally NOTARY PUBLIC My Commission Expires: 22 of 29 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless For Other Contractors and Subcontractors The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners from any and all claims for bodily injury (including death), personal injury, and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its Subcontractors in any tier, their employees, or agents. In the event the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 23 of 29 WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by this contract, the Contractor shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than: $100,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $100,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. If the Contractor has been approved by the Florida's Department of Labor, as an authorized self -insurer, the County shall recognize and honor the Contractor's status. The Contractor may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the Contractor's Excess Insurance Program. If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required. In addition, the Contractor may be required to submit updated financial statements from the fund upon request from the County. 24 of 29 GENERAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by this contract, the Contractor shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $200,000 per Person $300,000 per Occurrence $200,000 Property Damage An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed on or after the effective date of this contract. In addition, the period for which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of work by the County. The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. 25 of 29 PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, the Contractor, shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of the Contractor arising out of work governed by this contract. The minimum limits of liability shall be: $1,000,000 per occurrence/$2,000,000 aggregate 26 of 29 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL WAIVER OF INSURANCE REQUIREMENTS There will be times when it will be necessary, or in the best interest of the County, to deviate from the standard insurance requirements specified within this manual. Recognizing this potential and acting on the advice of the County Attorney, the Board of County Commissioners has granted authorization to Risk Management to waive and modify various insurance provisions. Specifically excluded from this authorization is the right to waive: • The County as being named as an Additional Insured — If a letter from the Insurance Company (not the Agent) is presented, stating that they are unable or unwilling to name the County as an Additional Insured, Risk Management has not been granted the authority to waive this provision. and • The Indemnification and Hold Harmless provisions Waiving of insurance provisions could expose the County to economic loss. For this reason, every attempt should be made to obtain the standard insurance requirements. If a waiver or a modification is desired, a Request for Waiver of Insurance Requirement form should be completed and submitted for consideration with the proposal. After consideration by Risk Management and if approved, the form will be returned, to the County Attorney who will submit the Waiver with the other contract documents for execution by the Clerk of the Courts. Should Risk Management deny this Waiver Request, the other party may file an appeal with the County Administrator or the Board of County Commissioners, who retains the final decision -making authority. 27 of 29 MONROE COUNTY, FLORIDA Request For Waiver of Insurance Requirements It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be waived or modified on the following contract: Contractor: Contract for: Address of Contractor Phone: Scope of Work: Reason for Waiver Policies Waiver will apply to: Signature of Contractor: Approved Not Approved Risk Management: Date: County Administrator appeal: Approved Not Approved Date: Board of County Commissioners appeal: Approved Not Approved Meeting Date: PROPOSER SIGNATURE 28 of 29 LOCAL PREFERENCE FORM A. Vendors claiming a local preference according to Sec this form. Name of Proposer/Responder 2-349, Monroe County Code must complete Date: 1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated at least one year prior to the notice or request for bid or proposal? (Please furnish copy.) 2. Does the vendor have a physical business address located within Monroe County from which the vendor operates or performs business on a day to day basis that is a substantial component of the goods or services being offered to Monroe County? The physical business address must be registered with the Florida Department of State as its principal place of business for at least one year prior to the notice of request for bids or proposals. (Please furnish copy of Florida Department of State Detail by Entity Name sheet showing Principal Address) List Address: Telephone Number: B. Does the vendor/prime contractor intend to subcontract 50% or more of the goods, services or construction to local businesses meeting the criteria above as to licensing and location? If yes, please provide: 1. Copy of receipt of the business tax paid to the Monroe County Tax Collector by the subcontractor dated at least one year prior to the notice or request for bid or proposal. 2. Subcontractor address within Monroe County from which the subcontractor operates: Tel. Number Print Name: Signature and Title of Authorized Signatory for Bidder/Responder: STATE OF _ COUNTY OF On this day of , 20 , before me, the undersigned notary public, personally appeared known to me to be the person whose name is subscribed above or who produced as identification, and acknowledged that he/she is the person who executed the above Local Preference Form for the purposes therein contained. Notary Public Print Name My commission expires: Seal 29 of 29 Exhibit A - Scope of Services 2017 The Proposer will be evaluated by County Staff on compliance with the below service requirements. By submitting a proposal, the Proposer agrees that these provisions will be part of the agreement between the parties. Deliverables: If necessary, the Proposer shall provide a policy Amendment, Endorsement, or Rider to the County to accommodate non-standard policy provisions agreed to by the Proposer. Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below Any policy issued shall be governed by and construed in accordance with the laws of the State of Florida applicable to Agreements made and to be performed entirely in the State. The Proposer shall maintain compliance with all federal, state, and local laws, ordinances, rules, professional license requirements and regulations that in any manner affect the work. The Proposer shall provide firm rates for the effective date of the policy based on the information provided in the RFP. Variations in actual enrollment shall have no effect on the rate proposal. The proposal shall be valid regardless of the final enrollment mix, number of Proposers, number of plan designs or outcome. All charges for any service or optional service must be clearly outlined in the pricing Exhibit C — STOP LOSS PRICING FORM. Exhibit A - Scope of Services 2017 Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below Disclose any commissions and/or service fees (if any are included) in your rate quotation, including the amount of the commissions and/or service fees, to whom they may be paid and your reason(s) for including them. Disclosure must be on an annual basis. The Proposer shall provide an experienced Implementation Manager responsible for the accuracy and timeliness of the implementation. The Proposer shall provide an Account Manager responsible for the overall relationship. The Proposer shall accept the provisions of the Monroe County BOCC Medical Plan as the controlling document for Stop Loss Claim Determinations. If you are unwilling or unable to comply please provide a complete coverage gap analysis between your policy and the current Plan Documents and provide this analysis with your Proposal. The Proposer must provide estimated renewal rates 180 days in advance of renewal. Exhibit A - Scope of Services 2017 Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below Proposer shall provide performance guarantees with financial penalties for non-performance. Performance guarantees should include: • Claim turnaround time • Claim payment accuracy No party to the Policy shall be required to enter into any arbitration proceedings related to the Agreement. The Proposer shall comply with the Florida Local Government Prompt Payment Act, Section 218.70, Florida Statutes. The vendor shall submit to the County an invoice with supporting documentation in a form acceptable to the Clerk. Following receipt of the invoice, the County will have 45 days to pay the invoice without interruption of service. The Proposer may terminate the Policy with ninety (90) days' notice to the COUNTY. The COUNTY may terminate the Policy with or without cause upon thirty (30) days' notice to the Proposer. COUNTY shall pay Proposer for work performed through the date of termination. As required by F.S. 119.071, the Vendor shall incorporate the following language into any agreement: Pursuant to Florida Statute §119.0701, Proposer and its Exhibit A - Scope of Services 2017 Service Requirement Yes Can Comply No Cannot Comply Yes, Can Comply but with Specified Deviations (please detail deviations below subcontractors shall comply with all public records laws of the State of Florida, specifically to: (a) Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement; (b) Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law; (c) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law; (d)Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the Proposer upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to Monroe County in a format that is compatible with the information technology systems of Monroe County; and (e) Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the Contractor or Exhibit A - Scope of Services 2017 Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below keep and maintain public records that would be required by the County to perform the service. If the Contractor transfers all public records to the County upon completion of the contract, the Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the Contractor keeps and maintains public records upon completion of the contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of records, in a format that is compatible with the information technology systems of the County. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT (305) 292-3470, bradley- brian(a�monroecounty-fl.gov, c/o Monroe County Attorney's Office, 1111 12th St., Suite 408, Key West FL 33040. The Proposer shall consent and agree to indemnify and hold Exhibit A - Scope of Services 2017 Service Requirement Yes Can Comply No Cannot Comply Yes, Can Comply but with Specified Deviations (please detail deviations below harmless the COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions, Officers, and the Employees, and any other agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, attorney's fees, or liability of any kind arising out of the sole negligent actions of the Proposer or substantial and unnecessary delay caused by the willful nonperformance of the Proposer and shall be solely responsible and answerable for any and all accidents or injuries to persons or property arising out of its performance. The amount and type of insurance coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the Proposer agrees to defend and pay all legal costs attendant to acts attributable to the sole negligent act of the Proposer. Request for Proposal Specific and Aggregate Stop Loss insurance Stop Loss Provider Name Date Completed Responses Effective Through IMPORTANT INSTRUCTIONS: Responses are limited to 1280 characters with a row height of 409. (Be aware' that extra lines and spaces are counted as characters in Excel.) You are able to increase the row height in this file to accommodate your response. Please make sure that your entire response is visible in the printed document.,' Please be brief - If you receive an error message you have exceeded the space alloted for your reponse. Please shorten your response to fit the available', space. Column D shows a count of the characters in your reponse please use this as a guide in determining remaining space. If you cannot complete your response in the space allocated, you will have the opportunity to provide supplemental information in other sections of your Proposal (TAB 3). Proposer Name Proposer Email Proposer Telephone 1. How long has your organization been in business? Year established: Additional Information: Has your company done business under other names? If yes, please provide Yes: historical background information. Identify any interests your organization may No: have with associated vendors (claims administrators, brokerage firms, managed If yes, please explain: care firms, etc.). Have you ever been suspended from writing this line of coverage? Yes: If yes, please describe. No: If yes, please explain: 2. Is your organization licensed to do business in all 50 states and U.S. territories? If Yes: no, identify the states/territories in which you are not currently licensed. No: If no, please explain: Page 1 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance 3. What percentage of the risk does your company assume? % If less than 100%, please identify additional reinsurer(s) and the respective If less than 100%, please explain: percentage of assumed liability. In what month do your reinsurance treaties renew? Month: Additional Information: 4. How many excess loss clients do you currently have? # of Clients: Additional Information: How much annualized premium do these clients represent? $ Additional Information: 5. Please provide your current A.M. Best Rating and Financial Size Category. AM Best:: Financial Size Category: Additional Information: 6. Please describe your disclosure process for pre -sale and at renewal (if different). Pre -Sale: Renewal: Additional Information: 7. Please provide a copy of your reinsurance contract and any amendments. Included: Yes: No: Additional Information: When was the enclosed contract adopted? Please provide a copy of your disclosure statements. Included: Yes: No: Additional Information: 8. In most cases, we require that your organization work directly with our Consultant Agree: rather than our client's claims administrator (TPAs, BCBS plans, carriers, etc.) on Disagree: such things as: Additional Information: 0 Renewals 0 Specific & Aggregate contract concerns 0 Plan Document/SPD adoption / approval 0 Plan amendments m�e� e� 9. What is the minimum group size for which your company will issue a proposal? Employee Lives: Additional Information: 10. What industries (if any) does your company consider to be "preferred"? Please list. 11. What industries (if any) does your company consider to be "ineligible"? Please list. 12. For public entities, do you have any restrictions on percentages of certain types of %: employees, such as police and fire employees? N/A: Additional Information: 13. Is your organization able to work with any claims administrator (TPAs, BCBS Yes: plans, carriers, etc?) No: If no, provide a listing of all U.S. based claims administrators with whom your If no, please explain: organization will do business. Please also indicate those that may have a "preferred" status and describe the advantage to the client in doing business with these claims administrators. Page 2 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance 14. Is your organization's excess loss contract guaranteed renewable? Yes: If no, describe your determination and notification methods. No: If no, please explain: Additional Information: 15. Does your second year contract automatically renew as a paid contract? Yes: No: If no, please explain: Additional Information: 16. Is your organization capable and willing to contact the claims administrator (TPAs, Yes: BCBS plans, carriers, etc.) or Case Management firm directly to obtain additional No: information related to large claimants? Additional Information: 17. When do you consider claims experience to be fully credible? Please describe. Specific: Aggregate: Additional Information: 18. Coverage is based on a no -loss / no -gain full transfer of coverage basis. If Agree: disagree, please explain. Disagree: If disagree, please explain: Additional Information: 19. We require firm rates at least 120 days prior to sale. If disagree, please explain. Agree: Disagree: If disagree, please explain: 20. Our Consultant considers coverage to be "bound" when the new carrier is in Agree: receipt of the binder check or first month's premium payment and executed Disagree: application. Do you agree with this statement? If disagree, please explain: If disagree, please explain. 21. Once firm rates are presented and coverage is bound, under which circumstances, if any, would your organization modify rates / factors mid year? 22. Are you able to propose a terminal liability option for a group that may, at some Yes: point in the future, choose to convert to a fully -insured arrangement? No: Additional Information: What is the cost to include this option? Cost: $ / ee / mo or: additional: % Additional Information: Is this option available at initial policy issue and also at renewal? Yes: No: Additional Information: 23. Does your organization offer "preferred" pricing based upon the client's Yes: network(s)? No: Additional Information: If yes, provide a listing of the networks your organization has rated; identify the status level for each and the associated percentage of savings discount. Space is provided for four (4) Networks. If necessary, list additional networks under Network Name 1 Status Level 1 % Of Savings "Additional Information". 1 2 3 4 Additional Information: 24. What is your range of commissions offered? Specific: Aggregate: Can you provide rates net of commission? Additional Information: Page 3 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance 25. Do you require that the prospective client purchase additional lines of coverage in Yes: order to bind stop loss coverage with your organization? If yes, outline your No: requirements. If yes, please explain: Do you offer pricing consideration when multiple lines of coverage are purchased? Yes: If so, please provide details. No: If yes, please explain: 26 Do you limit the percentage of covered lives that are COBRA and / or retirees? If Yes: yes, please provide details. No: If yes, please explain: 27. What is the minimum individual specific deductible your company offers? $ Additional Information: 28. What percentage discount / credit is applied to your "first year" (i.e., 12/12) specific pricing? 29. How long are your specific rates guaranteed? Are you willing to guarantee these rates for a period longer than twelve months? If Yes: yes, will this impact rates? If yes, how so? No: If yes, please explain: 30. Please describe the specific incurred/paid contract periods (i.e., 12/12, 12/12 Yes: No: 12/15, etc.) that you offer. 12/15 Yes: No: 12/18 Yes: No: 15/12 Yes: No: 18/12 Yes: No: 24/12 Yes: No: Other: Additional Information: 31. Is there a run-in limit on specific stop loss? If yes, what is the percentage or Yes: formula? No: If yes, please explain: Additional Information: 32. What is the maximum individual lifetime maximum amount your contract Unlimited Yes: No: recognizes as eligible (i.e., $2 million, $5 million, unlimited)? $ million per individual Additional Information: Do you have more than one option available? Yes: No: Additional Information: 33. Confirm that your specific coverage(s) can include the following benefits: A) Yes: No: A) Medical B) Yes: No: B) Prescription Drug Other: Additional Information: 34. Do you laser individuals at policy inception? Yes: No: Additional Information: Do you laser individuals at renewal? If yes, indicate whether this applies only to Yes: those Iasered under the initial contract terms, or if potentially large claimants are No: reviewed annually. If yes, please explain: If you do not laser, will you laser upon request and offer a lower premium? Yes: No: Additional Information: If you do laser, will you offer a premium increase instead of the laser? Yes: No: Additional Information: Page 4 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance 35. Does your organization offer the specific deductible on a standard, aggregating Standard: and / or family basis? Aggregating: Family: Other: Additional Information: OEM!!! 36. What percentage discount / credit is applied to your "first year" (i.e., 12/12) aggregate pricing? 37. How long is your aggregate premium guaranteed? Are you willing to guarantee these rates for a period longer than twelve months? If Yes: so, how would this impact rates? No: If yes, please explain: 38. Please describe the aggregate incurred / paid contract periods (i.e., 12/12, 12/12 Yes: No: 12/15, etc.) that you offer. 12/15 Yes: No: 12/18 Yes: No: 15/12 Yes: No: 18/12 Yes: No: 24/12 Yes: No: Other: Additional Information: 39. Confirm that your aggregate coverage can include the following benefits: A) Yes: No: A) Medical B) Yes: No: B) Prescription Drug Other: Additional Information: 40. At what percentage of expected claims can the aggregate corridor be set? 110%: 115%: 120%: 125%: Other: Can you quote more than one option? Yes: No: Additional Information: 41. Do you retain the right to modify your aggregate factors based on experience Yes: subsequent to the proposal? No: Additional Information: 42. Does your aggregate contract impose an annual maximum claim liability? If yes, Yes: identify the amount. No: If yes, please explain: Are there any other options available? Please explain. Yes: No: If yes, please explain: 43. Please describe the specific incurred / paid contract period (i.e., 12/12,12/15, etc.) 12/12 Yes: No: that you offer. 12/15 Yes: No: 12/18 Yes: No: 15/12 Yes: No: 18/12 Yes: No: 24/12 Yes: No: Other: Additional Information: 44. What percentage, if any, of annual paid claims applies to initial run-in limitations %: on your aggregate contract? N/A: Page 5 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance Will your organization waive run-in limitations? If yes, at what cost / Yes: percentage? No: If yes,: $ / % Additional Information: 45. What is your minimum attachment point percentage or formula for first year cases? Does this differ for renewals? Yes: No: Additional Information: 46. The client requires preliminary renewal information from their vendors 180 days Yes: in advance of their actual renewal. Is your organization able to comply with this No: request? If no, explain. If no, please explain: Additional Information: 47. What information do you require from the client, their claims administrator and / or Specific: Consultant to issue a renewal? Be specific regarding all claim experience and Aggregate: disclosure requirements. Additional Information: 48. We require renewal rates and factors to be finalized no later than fourty five (45) Agree: days prior to the date of renewal. If disagree, explain. Disagree: If disagree, please explain: Additional Information: 49. What contract features are subject to adjustment from preliminary to final renewal? A) Yes: No: A) Specific Rate(s) B) Yes: No: B) Aggregate Factor C) Yes: No: C) Aggregate Rate Other: Additional Information: e 50. What are your proof of claim and timely filing requirements for claim reimbursement requests? 51. What are your company's timing requirements with respect to notification and claim filing? 52. Who has final claim decision -making authority with respect to specific and aggregate claims? 53. When do you consider a claim paid? Please be specific. 54. Who defines what the reasonable and customary amounts are? 55. Explain your organization's underwriting guidelines for incorporating plan changes. Must plan changes be approved in writing prior to implementation and / or Yes: renewal? No: Additional Information: 56. Do you designate a Large Case Management firm with whom the claims Yes: administrator (or Pre-cert vendor) must coordinate potentially catastrophic cases? No: Additional Information: 57. Are there any conditions or circumstances (i.e., diagnosis, procedure, medical Yes: services, etc.) that require pre -approval by your case managers? If yes, please No: list. If yes, please list: Additional Information: 58. Is there a Transplant Center of Excellence provision in your contract? Yes: No: Additional Information: If so, is this a voluntary or mandatory program? Explain the consequences of non- Yes: compliance. No: Additional Information: Page 6 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance If voluntary, do you offer any discounts for including it in the plan? Yes: No: If yes, please explain: Additional Information: 59. Are case management fees reimbursable to the client? Yes: No: Additional Information: Are case management fees included in an individual's lifetime maximum benefit Yes: calculation? No: Additional Information: 60. Will you allow "non -covered" alternative care, if approved by your case Yes: managers? No: Additional Information: 61. Are there any charges and/or fees that standardly do not apply to specific or Yes: aggregate coverage? No: Additional Information: 62. Provide a listing of all specific conditions or diagnosis your organization considers to be "catastrophic". 63. If the client is a health care facility or provider (i.e., hospital, physician group), are Yes: charges performed at their facility reimbursed at a lesser amount than other No: charges? If yes, please explain: Additional Information: 64. Does your contract recognize all eligible employees, spouses, domestic partners, Yes: dependents, FMLA, retirees (if applicable), and COBRA beneficiaries as defined No: by the employer's Plan Document / SPD and Supplement to the plan as provided? Additional Information: 65. Other than the employer's Plan Document / SPD, does the contract allow for Yes: guidelines found in the employer's Employee Handbook (i.e., leave of absence No: policy)? Additional Information: 66. Is there ever a situation in which you would deny a claim that was a covered Yes: benefit in an employer's Plan Document / SPD you had previously approved? No: Additional Information: 67. Please identify any restrictions and limitations pertaining to an off- anniversary termination. 68. Please detail the process involved in obtaining coverage for out -of -contract services. 69. If PPO access fees are payable as a percentage of savings, are the charges in Yes: excess of the specific deductible reimbursed? No: Additional Information: 70. Your contract must waive "Actively at work" provisions, based upon HIPAA Agree: guidelines. Disagree: If disagree, please explain: Additional Information: 71. If a client acquires a new company during the contract year, are you willing to Yes: waive the actively at work, dependent non -confinement and pre-existing condition No: limitation provisions for the newly acquired employees, their dependents, spouses, If no, please explain: domestic partners, FMLA, retirees (if applicable), and COBRA beneficiaries? Additional Information: 72. The County requests that Plan Document / SPD be the controlling document for all All contract provisions will mirror the claim determinations. If your contract does not rely on the employer's Plan Plan Document/SPD.: Document / SPD for stop loss claim determination, please explain your organization's position regarding coverage for the listed provisions. All provisions will NOT mirror the Plan Document/SPD.: If not, please explain by provision. a) Work -related exclusions (worker's compensation vs. any gainful a) employment) We will match the Plan Document: The stop loss contractprevails: Page 7 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance b) Pre-existing Conditions b) We will match the Plan Document: The stop loss contractprevails: c) Non -medically necessary charges c) We will match the Plan Document: The stop loss contractprevails: d) Experimental and investigational procedures, drugs or treatment d) We will match the Plan Document: The stop loss contractprevails: e) Biologically -based mental disorders e) We will match the Plan Document: The stop loss contractprevails: f) Non -biologically -based mental/nervous, alcohol and substance abuse f) We will match the Plan Document: The stop loss contractprevails: g) Administrative, investigative and legal services, including compensatory & g) punitive damages We will match the Plan Document: The stop loss contractprevails: h) Charges recoverable by a third -party (subrogation and/or Medicare) h) We will match the Plan Document: The stop loss contractprevails: i) Expenses that are incurred as a result of war i) We will match the Plan Document: The stop loss contractprevails: j) Expenses that are incurred as a result of an act of terrorism on domestic j) and foreign soil We will match the Plan Document: The stop loss contractprevails: k) Expenses incurred while committing assault / felony k) We will match the Plan Document: The stop loss contractprevails: 1) Charges related to attempted suicide 1) We will match the Plan Document: The stop loss contractprevails: m) Charges related to self-inflicted injuries m) We will match the Plan Document: The stop loss contractprevails: n) Charges related to hazardous pursuits n) We will match the Plan Document: The stop loss contractprevails: o) Please include any other significant provisions you feel need addressed o) along with your organization's position regarding those provisions. If you do not mirror the employer's plan document and Supplement to the Plan, then please summarize your stop loss contract exclusions / limitations not listed above and how it might affect what the employer has in their plan If you do not agree to mirror the employer's plan document, then will you agree to review the employer's plan document, if provided, as part of your pre -sale activities, and point out any potential gaps between your stop loss policy and the employer's plan document, and if possible, offer solutions? Identify whether your excess loss contract has any limits related to the following Coverage for all benefits in the employer's Plan Document are covered provisions: under the stop loss contract: Coverage for all benefits in the employer's Plan Document are NOT covered under the stop loss contract: If there are limitations, please provide detail by provision. Limitation Detail a) Late Entrants a) b) Annual Open Enrollment b) c) Section 125-qualified change in status events c) d) Domestic Partner coverage d) e) Transplants (describe any requirements and limitations) e) f) Biologically -based mental disorders f) Page 8 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance g) Non -biologically based mental/nervous and/or substance abuse g) h) Alternative therapies (e.g. acupuncture, homeopathic, naturopathic) h) i) Attempted suicide (whether sane or insane) i) j) Acts of war j) k) Acts of terrorism on domestic and foreign soil k) 1) Commission of a felony 1) Additional comments If you do not mirror the employer's plan document, then please summarize your stop loss contract exclusions / limitations not listed above and how it might affect what the employer has in their plan document. 74. What is your organization's average turnaround time for specific claims Days: submitted for reimbursement? Additional Information: 75. With respect to specific claims submitted for reimbursement, please describe any limitations (i.e., minimum dollar amounts). 76. Is the maximum benefit for specific excess loss the plan's lifetime Yes: maximum amount less the specific deductible? No: Additional Information: 77. Do you offer advance funding or quick pay options for specific claims? If so, Yes: please provide details including any additional cost. No: If yes, please explain: Additional Information: 78. When do you require notification of a specific claim? % of Specific Deductible: or: Amount of Claim: or: Other, please explain: Additional Information: 79. If there is an aggregate claim, is an audit part of your standard process? Yes: No: Additional Information: 80. What is your organization's average turnaround time for aggregate claims Days: submitted for reimbursement? Additional Information: 81. With respect to aggregate claims submitted for reimbursement, please describe any limitations (i.e., minimum dollar amounts). 82. Do you offer advance funding or quick pay options for aggregate claims before Yes: end of plan year? If so, please provide details, including any additional cost. No: If yes, please explain: Additional Information: 83. How often do you require aggregate claim reporting information? 84. Clinical Trials How do you comply with the guidance regarding participation in clinical trials? 85. External Review Appeals Under health care reform, non-grandfathered plans must include an external review option. A claim filed in a timely manner (consistent with the requirement of the stop -loss policy) and denied by the claim administrator is subject to appeal. A claim properly incurred and adjudicated (denied) in one coverage period and subsequently appealed by the participant, including an external review, could easily extend beyond that coverage period. How does your organization address claims that were denied in one coverage period and paid in another coverage period? SIGNATURE: Page 9 of 10 Request for Proposal Specific and Aggregate Stop Loss insurance understand and hereby certify that all informationprovided in this RFP response ocument is true and correct. I' am authorized to represent and bind my company these responses. This questionnaire was completed by(Name 1 Title):' On behalf',of(Company Name 1 Address):', NOTE: Your typed name and date will be Phone Number: E-Mail Address: Page 10 of 10 EXHIBIT C - STOP LOSS PRICING FORM 15/12 CONTRACT BASIS Complete the exhibit by entering the PEPM Cost for your quotes for each of the options requested. Please enter your assumed enrollment for each rate type and use this in determining your estimated annual premium costs. Enter your monthly estimated enrollment in A 37 STOP LOSS INSURANCE Assumed Enrollment {Vendor Name} POLICY PROVISION Option 1 Option 2 Option 3' Specific StoLoss Specific Deductible $300,000 $500,000 $750,000 Lifetime Maximum Unlimited Unlimited Unlimited Polic Term 15/12 15/12 15/12 Specific Pricing] Single $$$ $$$ $$$ Employee + Spouse $$$ $$$ $$$ Employee + Child(ren) $$$ $$$ $$$ Employee + Family $$$ $$$ $$$ Composite $$$ $$$ $$$ Aggregate Stop Loss Corridor 125 % 125 % 125 Annual Maximum Unlimited Unlimited Unlimited Policy Term 15/12 15/12 15/12 Aggregate Pricin Single $$$ $$$ $$$ Employee + Spouse $$$ $$$ $$$ Employee + Child(ren) $$$ $$$ $$$ Employee + Family $$$ $$$ $$$ Composite $$$ $$$ $$$ Aggregate Factor Composite $$$ $$$ $$$ Annual Attachment Point $$$ $$$ $$$ Total PEPM Stop Loss Premium 0.00 0.00 0.00 Estimated Enrollment: 1621 TOTAL ESTIMATED ANNUAL PREMIUM COSTS $0 $0 $0 Performance Guarantees State guarantee and amount at risk all Underwriting Contingencies and Assumptions in this Section, including any lasers EXHIBIT C - STOP LOSS PRICING FORM PAID CONTRACT BASIS Complete the exhibit by entering the PEPM Cost for your quotes for each of the options requested. Please enter your assumed enrollment for each rate type and use this in determining your estimated annual premium costs. Enter your monthly estimated enrollment in A 37 STOP LOSS INSURANCE Assumed Enrollment {Vendor Name} POLICY PROVISION Option t Option 2 Option 3' Specific Stop Loss Specific Deductible $300,000 $500,000 $750,000 Lifetime Maximum Unlimited Unlimited Unlimited Polic Term PAID PAID PAID Specific Pricing Single $$$ $$$ $$$ Employee + Spouse $$$ $$$ $$$ Employee + Child(ren) $$$ $$$ $$$ Employee + Family $$$ $$$ $$$ Composite $$$ $$$ $$$ Aggregate Stop Loss Corridor 125 % 125 % 125 Annual Maximum Unlimited Unlimited Unlimited Policy Term PAID PAID PAID Aggregate Pricing Single $$$ $$$ $$$ Employee + Spouse $$$ $$$ $$$ Employee + Child(ren) $$$ $$$ $$$ Employee + Family $$$ $$$ $$$ Composite $$$ $$$ $$$ Aggregate Factor Composite $$$ $$$ $$$ Annual Attachment Point $$$ $$$ $$$ Total PEPM Stop Loss Premium 0.00 0.00 0.00 Estimated Enrollment: 1621 TOTAL ESTIMATED ANNUAL PREMIUM COSTS $0 $0 $0 Performance Guarantees) State guarantee and amount at risk all Underwriting Contingencies and Assumptions in this Section, including any lasers N a MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Total Net Paid Prescription Drug and Medical Claim Summary Month Enrollees Rx $168,838 Medical $1,192,721 Medical Total Oct-09 1,588 $1,361,559 Nov-09 1,582 172,722 1,066,022 1,238,744 Dec-09 1,587 198,020 1,720,095 1,918,115 Jan-10 1,594 176,372 697,116 873,487 Feb-10 1,599 177,655 986,646 1,164,301 Mar-10 1,594 211,999 1,124,366 1,336,365 Apr-10 1,600 201,399 785,118 986,517 May-10 1,600 183,308 914,499 1,097,806 Jun-10 1,598 190,794 1,043,445 1,234,239 Jul-10 1,600 195,522 816,370 1,011,892 Aug-10 1,596 197,355 879,241 1,076,596 Sep-10 1,589 214,174 201,061 793,675 761,233 1,007,849 Oct-10 1,598 $962,294 Nov-10 1,598 204,259 1,109,555 1,313,813 Dec-10 1,597 214,174 1,290,432 1,504,605 Jan-11 1,600 239,704 1,124,618 1,364,322 Feb-11 1,597 183,576 722,663 906,239 Mar-11 1,595 208,054 924,985 1,133,039 Apr-11 1,592 209,798 972,425 1,182,223 May-11 1,591 211,681 1,256,565 1,468,246 Jun-11 1,587 206,102 1,205,139 1,411,241 Jul-11 1,588 194,953 1,003,869 1,198,822 Aug-11 1,595 226,269 717,596 943,865 Sep-11 1,584 202,521 1,152,396 1,354,917 $944,866 Oct-11 1,588 $161,630 $783,236 Nov-11 1,591 177,409 527,875 260,262 965,546 Dec-11 1,593 187,183 522,962 456,951 1,167,097 Jan-12 1,599 197,650 204,892 440,308 842,850 Feb-12 1,597 211,115 1,112,463 418,426 1,742,004 Mar-12 1,614 209,259 316,979 964,109 1,490,347 Apr-12 1,621 191,404 210,676 943,373 1,345,453 May-12 1,607 210,016 103,642 802,083 1,115,741 Jun-12 1,612 200,431 53,088 585,872 839,391 Jul-12 1,606 196,740 43,628 761,046 1,001,414 Aug-12 1,605 205,087 19,808 859,754 1,084,650 Sep-12 1,594 137,880 (2,254) 811,743 947,369 $1,307,050 Oct-12 1,606 $208,722 $13,901 $1,084,427 Nov-12 1,606 $198,588 $894,067 $1,092,654 Dec-12 1,599 $190,397 $819,586 $1,009,983 Jan-13 1,593 $228,265 $819,511 $1,047,775 Feb-13 1,593 $222,449 $968,891 $1,191,340 Mar-13 1,592 $208,605 $666,715 $875,319 Apr-13 1,589 $237,273 $775,449 $1,012,721 May-13 1,589 $226,839 $783,895 $1,010,734 Jun-13 1,590 $222,955 $709,978 $932,933 Jul-13 1,589 $220,198 $985,244 $1,205,442 Aug-13 1,603 $215,291 $832,454 $1,047,745 Sep-13 1,602 $220,001 $690,711 $910,712 $952,267 Oct-13 1,598 $247,899 $704,368 Nov-13 1,614 $220,918 $718,832 $939,750 Dec-13 1,610 $240,404 $842,260 $1,082,664 Jan-14 1,606 $224,245 $638,022 $862,267 Feb-14 1,602 $211,370 $900,504 $1,111,874 Mar-14 1,602 $222,684 $900,367 $1,123,052 Apr-14 1,601 $237,479 $719,946 $957,426 May-14 1,605 $246,035 $756,365 $1,002,399 Jun-14 1,597 $226,400 $732,953 $959,354 Jul-14 1,597 $256,370 $978,097 $1,234,466 Aug-14 1,596 $262,079 $899,497 $1,161,576 Sep-14 1,595 $292,711 $894,864 $1,187,575 $1,377,697 Oct-14 1,605 $229,487 $1,148,209 Nov-14 1,604 $237,026 $833,995 $1,071,021 Dec-14 1,597 $300,612 $882,134 $1,182,746 Jan-15 1,591 $306,699 $832,283 $1,138,982 Feb-15 1,583 $269,368 $670,562 $939,930 Mar-15 1,593 $339,055 $902,384 $1,241,439 Apr-15 1,590 $325,345 $800,592 $1,125,937 May-15 1,598 $329,886 $813,524 $1,143,410 Jun-15 1,592 $329,832 $983,700 $1,313,532 Jul-15 1,592 $348,993 $765,684 $1,114,677 Aug-15 1,581 $283,561 $1,175,399 $1,458,960 Sep-15 1,582 $314,399 $1,111,604 $1,426,003 Oct-15 1,588 $316,611 $1,070,336 $1,386,947 Nov-15 1,588 $289,929 $1,054,951 $1,344,880 Dec-15 1,580 $285,826 $1,128,908 $1,414,734 Jan-16 1,577 $276,866 $728,823 $1,005,689 Feb-16 1,580 $307,561 $758,023 $1,065,584 Mar-16 1,587 $337,615 $1,139,862 $1,477,477 Apr-16 1,584 $288,758 $778,891 $1,067,649 May-16 1,575 $349,196 $1,173,918 $1,523,114 Jun-16 1,572 $330,753 $1,255,417 $1,586,170 Jul-16 1,573 $281,245 $1,079,457 $1,360,702 Aug-16 1,580 $332,618 $1,388,731 $1,721,349 Sep-16 11588 $340,186 $1,056,087 $1,396,273 Oct-16 1,578 $298,103 $975,187 $1,273,290 Nov-16 1,588 $353,210 $1,068,790 $1,422,000 Dec-16 1,591 1 $315,082 $1,313,937 $1,629,019 2009/10 19,127 $2,288,159 $12,019,314 $0 $14,307,472 2010/11 19,122 $2,502,150 $12,241,475 $0 $14,743,626 2011/12 19,227 $2,285,804 $3,896,996 $7,303,927 $13,486,728 2012/13 19,151 $2,599,582 $13,901 $10,030,926 $12,644,409 2013/14 19,223 $2,888,594 $0 $9,686,074 $12,574,668 2014/15 19,108 $3,614,264 $0 $10,920,069 $14,534,332 2015/16 18,972 $3,737,164 $0 $12,613,404 $16,350,568 2016/17 4,757 $966,395 $0 $3,357,913 $4,324,308 Last 12 Mos - $3,811,193 $0 $12,717,122 $16,528,315 2009/10 $119.63 $628.40 $0.00 $748.02 2010/11 $130.85 $640.18 $0.00 $771.03 2011/12 $118.89 $202.68 $379.88 $701.45 2012/13 $135.74 $0.73 $523.78 $660.25 2013/14 $150.27 $0.00 $503.88 $654.15 2014/15 $189.15 $0.00 $571.49 $760.64 2015/16 $196.98 $0.00 $664.84 $861.83 2016/17 $203.15 $0.00 $705.89 $909.04 Last 12 Mos $200.87 $0.00 $670.27 $871.15 Utilization Summary By Group Carrier ID: MCBOCC Carrier: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Entered Date: 1 /1 /2017 - 1 /31 /2017 Report Run Date: 2/7/2017 9:38:19 AM > Total Net Rx Count for selected groups is 3,041 > Total Plan Cost for selected groups is $252,203 > Plan Cost % for Specialty drugs is 31.10% Utilization Summary By Group Carrier ID: MCBOCC Carrier: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Entered Date: 2/1/2017 - 2/28/2017 Report Run Date: 3/8/2017 4:05:08 PM > Total Net Rx Count for selected groups is 2,762 > Total Plan Cost for selected groups is $235,740 > Plan Cost % for Specialty druas is 31.91 % Utilization Summary By Group Carrier ID: MCBOCC Carrier: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Entered Date: 3/1/2017 - 3/31/2017 Report Run Date: 4/4/2017 9:12:44 AM > Total Net Rx Count for selected groups is 3,057 > Total Plan Cost for selected groups is $285,656 > Plan Cost % for Specialty drugs is 36.05% N m M m M m M m M m N M 0 0 p p 0 0 0 0 0 0 0 0 0 0 0 0 0 O 0 0 0 0 0 p 0 0 0 0 0 0 p p N O N N O itl O N N T V O N M LL'J O O V O Ii1 �,.� 4J O O V O In M N O O V 0 N M LLJ 0 0 V O N M Cf N M O OI CO 1� n ti O O > 0 0 0 0 0 > 0 0 0 0 0> O O O O 0 > 0 0 0 O O > L. 0 CL 0 L- CL 0 4- r_ 0 �2 z U) 4) T) 13 cu 0 cu 0 CL q LU z C14 LO LU 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CL 0 CL 0 r_ 0 .2 �a T �a 0 7R 0 LM CL CL N LU z LO LU L) z LU w LU CL x coU c 0} ) a.. z w 2 L) qi E L8 Packet Pg. 1213 §(( \Packet § 14 }\\\} } \\\\\\\ \} /: ( \j\\\\\(} \ } //§\}(\ / \�) j > \ \ /\ \ < / /6 /6 \/ \\\\2 /\\ \ \ \ < G2f \)\\{\\\% /!§bE§E52 /\\� o"W )\()/ \)\ \\. \(\\\\.\\ z ' z - z -z -z z- z. - -z -z z -z ya LLF F LL F F� F: F LLF � F : F:LL F F F� F F:LL F au �w� a4 �.-R E� z z z z z gS g p3 p5 I a rc� rc rc3 a:. - - - - - o yaw a - F F i F F F F� FF 3S oa ow w FQ 3 3 3 3 3- 7 o d a Fa .5 5 d F pF pF=. 'oo. d pF pF d FM.�F € o€ E. g C� u a a� d Fpa F = o ot��F zap a� z 3�F �a� a� 3a� a� F FY F F<F F F F F z �o.F F F. F a F z� F z� w�wt: S- s ws �: F F �. F F F F € € T T T moo.< R Z F o FF� F F aF F aF43�39? J F F F F F F € €Z€ €p F d S S m<z S S a S S F �a �a L. 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F�F F FLLF F F: a_ a s ° F F LLF LLF. °° a0 lw ' ¢ _ F wW. ¢ _ _ _ _ — _ — - - 3 a� ¢ Q x 3 3 �2 -2F m� w r € �� 2 2 u za a�o F F 72 a� z ¢ -0 3 ag F aF a. a a € o a F.F = =a a a ow F°� — — Q w S F F w F o F 9 US — a 1. FwF—� dg J °a a a a _ p i 3 s �a �a L. CL 0 CL 0 r_ 0 .2 �a T �a 0 7R 0 LM CL CL 04 CY LU z LO BLU{ b) z LU w LU CLtr� mi LU co L) z w L)p�pq F— qi E L8 Packet Pg. 1219 �F �F 2 z 2 2 z. 2 w Z 2 z z 3 Spy 3 5 5 p3 p5 71 oa a ¢q oo F F6 63 : S F u _ F°U� - _ w F — R c �' :a m rc K Z F€ F a _ F ol F z ; - _ ao�a a. -- - _ Z ¢ n O _Q — — z F F O p i� gO — 3 o o . . Oz a�o �¢a� �� F c� 3 3 3 ��F8a F°> lw- 5 og 3 uo�=O��€ - 3...:5 °¢oZ3 - -� Fz g-Fa F:� Z3 v"i Z...� FF 3 F 2 F F F F F O F 3 FZ F Fz FZF € -- g _ i F u�u� F gF —u�u� u�u� — P. F Fz k k 3 F F 5 F S - O �F SO Za J_2o _ Fi a a ^dug _�..� - ¢=nw>�nxun2m �a �a L. CL 0 CL 0 r_ 0 .2 �a T �a 0 7R 0 LM CL CL N CY LU z 04 LO BLU{ b) z LU w LU CL x coU c L) z w p� Au E Packet Pg. 1220 _ _ _ _ m m m — F FF — — to FF to to F F FF FF F F F. F F F F ¢ — F — — F F F F F F F F z z z z rc z �. g Fi Fi Fi j j j = Fi Fi Fi Fi Fi Fi O Fi g g IN IN 10 1 WO 3 71 a Fo _ _z zor 0 017-7 9 zQ oa o� :F - w3�43 Yak 3y� F Z 7-7 ug S 11 �w 3 � �� ° 4 o € a3 aF ° rco 0 0_ w rc '� F rca 'wF —z Z p fl. aF z o- za F� � aF 3 o a aF r a _ F �F _ w<9w N :€ Z a F� F F Z Z F w z o a � LLaLLr LL �a �a L. CL 0 CL 0 r_ 0 .2 �a T �a 0 7R 0 LM CL CL 04 LU z 04 LO BLU{ b) z LU w LU CL x LU co L) z w L) E Et5 Packet Pg. 1221 M ] S [ \/}\\\\\\\\}\\}\\\ . o. \(\ \\ \\\ q §2 . . . 9 . \ \ .. .. % Q.726 - \\ / »§f\ ^ 4/\()\ :. . ./ _ . : \\ a \\\(\\ \\(\\ )w 2a 3 J& q % d -a66p�Q\\={g zzz` \\\ \\(\ / \\(/\/ w, � Q/b!\2%29l9 /\ /g/ gb)R\/ q// /%R}&\//Q6 - /}\/\/\Q y 7 ej\:&27\J 6\ \ \/\ 7—z � � . / \ / / 1 5p7o \ z a a Packet Pg. 1223 i i — — ',. — O o 4o. 4 4 i o o F ¢ o a mUF S = NSFFS Fo FFg FFg FF — — — — — 3 : ?'FUo LL ol IU33v 33.Us -- F3 F oawl : 3 F �— w. �rcZ€ F ��F€F— _ yF F :. F°O o - F - aa_ 3 �3 3 s �3 € ° m F F i F F F 5 J eR 2 2 a F d ° u — a� F F F 3 z �o z _ 3g k cF qw—o - - F mLL - �� F3 3 o o _Fo 3 F F F F F F F F c F F W ° z a F a 9-2 c =1. So o �a �a L. CL 0 CL 0 r_ 0 .2 �a T �a 0 7R 0 LM CL CL 04 CY LU z 04 LO BLU{ b) z LU w LU CLtr� mi qLUqg� cX Ly�p)g a�n z w L) qi L8 \ \\\\\\\\\/\\\ § «\ \ //! ()// \\\( /)(-)§(\(\(\(/ \ \� \((\ / \\\§ / / \ -10 )/(\§\§\§\/ / OTT Omo. 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CL 0 CL 0 r_ 0 .2 �a T �a 0 7R 0 LM CL CL N CY LU z CL L6 LU L) z LU w LU CL x LU co L) a.. z w L) E Packet Pg. 1229 w w m w m w m: m w w m � a LL a LL a a s LL a. : w w m m LL LL LL LL z z - z - - - - F F : F sw � a qg F u FF � � _ � F F Oo 3 �p o F o 7 7 F W� F �a F rc F oaow F € ¢_ F € 4 t R:T d 3 _ N z> W=a �o ¢.a F F� -z - F 3_-Fz'7 9�-- �a 3o� F > = 33 F x Z ¢wlF F F Fa F ¢ wl IN-1z w €o a 3 F F F o Fz w z �NF Fz J F am F F a Fw 1. z «o z _ __ a _ _ S a a a a a s a a \ § § \ \ \ \ \ \ \ \ \ \ \ \ 2 \ \ \ \ \ \ \ . . . . . . . . ` \! . . % - - - o ^ ^ ^ } ) ) } ) ) \}d ) ) \ ]t t j \ /( 3 \ j / /( 3 \ § / j / j \ j \ § g[ g[ _ \\\\\ \\(\\\\/\\ \\\\({\/ \\\\\\\\\ \ \/ \o {\\\\ \p | ! \ 9i ©= oo, 9! 9i _ (\=,z 2G 3\m<dG JG \G xdg y« 9! « ! ! / ,y 9 § dG S;6 @g a yg, \\ ! 6:§/ 9\z \\ /2 /6 /2}<i;w\ 9)4c @5 2:�J,» s »\e wb \!R /G ®Qs; :! 2» 92 O0 ) - G!%J 2/ 2Q \d 2/ 2/ 2/3»®!C£ /\\}\\\( yD «J » Rw y yw,,, . 2 ,«=«a as sa a z Q!d#/:QW Q aG�°: . - Q=G§£/ \% \2 \/ \\ \/}/ \\/g§/@l6ivR 2 yA \ § \ /\G1/%/§J fGa\` � \ A! ]§ e \\{\_ 2;§ \;\ \\\ Q[/ Q / 9!\(/ \/9 Q/acme=x2= \\ G[y#!e; 9 G44 d G` \ a=r9a2c;�lg 3ca2=GJ;6\«R\\d : 6 e x mq &:gz« s=4!« s a, ;/ « sae:v e,e=4 9,a:§ g G ,., , \ \( :gib p / 3 y G a ©`& ==w e:a ©:a ©b s m: x 5 4 R!& g;9 g!& g!& g w b:;{ v s a £:J s�«,s w:Z:£ C a B;. g 6 4Rla BEd:« J:%§f » @ ,,rJ e / /\ 9 / G)§ 2§\ 54/ Q4/ D 6 \E}! \ a / G4/ 9;£§@ \!%;§ \C 4 l 9 @ai E.v s a 2 « a a _�=_�=a�,_� as a=x=, >�:_�:&===«� w a= ,;w 6 « s R w @ a w,R R,a R!e w!% R « a y.a wlg �f 2:2 2 ©®•2 ©° ° 2:4:/r-, e / « R< ,,e 9J e e w a p a:w a:r a:p a=% s e g=!.e a:K x;@ D :;; ell �ell o \o ( \ ƒ ) { ) ()()()({() :�S GS72 \\T — — g14 LO F ofF FF of : F F 2-0 w 3 LL ow m8 w — — F � m a o o o CL _.. z w 91 a 01 - - w 3 ap�o o `z �w w�- rc� 107. w Fww� : F Q�� F �F F F F � F Ho F 19F F 19F. g w 3i�3w3is s3 w3az ��3 3 03 3 3LLo3 3 Qa F— F a fan 1O : F� F F F 3F 3 F F F F. F F4,5 F. F Fa K W.F- w FawwaFaww F w� aFwo rcF w° a cp - 2 3 rc 3 2p 3 2 6@ 2 ao� �. �._ - c w oO�uoa wa za F F F T � -� � SF F �._ �._ .m9° aw F F F F SO Owuwi°zu F FFF F F F£ F FF F F F F _ �� Fa w�9waQ �� .F FQ F �i o LLF �irwz :. Fi Fi ¢ Fi Fi Fi 'c o q F. _ E n �.. : e m �o �o �o a ➢. a n. n n : e e n m �o n : �o �o c Packet Pg. 1233 o :. a5 z F lo O F F z z y�rcrcrc rcrc rcrc rc. 5 IrI 1 1;I grid O> .d..a.a.a..u.a i�: ....... a.. a. u. a.. u. a. a... a. a. d. .. .0 .d..d pg _ z z IF F z z a w z z g F g F z F F a - F F F F a : F a F a a a LL a a a a a rc F �O rz 10oP oo . w aw a w Fi w Fw wa 3wFa w w w wi-5 w —� __o n 5 n a n 5 a 2rc olol;02o2o7 5J 5 — $ O F i a FFz FFF F 3F 3F E F y a F a a75 p F 5 z o- - - a Z - - w F w a F - w w w w w z F— F : :€ o Fi Fi. z Fi z Fi z 5 O C : Fi z Fi Z F. F Fi. z Fi Fi. z Fi F w F g 5 F F3FF F aF. a F Q.F F� F F F F. a F w F — — — rasa �a gas a�a'. �a saga as as a�a'.�as a.�a. �a sas a'.o_aI..'.I.. $a '.I. asa I.a ',.I.. ''. 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N❑ z � d ❑ a to >a a ❑ vI Z K N Z K� d: a a ❑ tn¢ a ❑ v]: 3❑ : K ZS S ZS ry L. 0 CL 0 L- CL 0 4- r_ 0 �2 T 0 7R 0 LM CL CL q LU z Ln LU L) z LU CL x LU co L) z w L) 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 i 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. 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 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. 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? Read the "BlueCard (Out -of -State) Program" section. • 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. Overview of How BlueOptions Works Whenever you need care, you have a choice. If you visit an: In -Network Provider Out -of -Network Provider You receive In -Network benefits, the You receive the Out -of -Network level of highest level of coverage available. benefits — you will share more of the cost of your care. You do not have to file a claim; the claim You may be required to submit a claim form. will be filed by the In -Network Provider for you. The In -Network Provider* is responsible You should notify BCBSF of inpatient for Admission Notification if you are admissions. admitted to the Hospital. *For Services rendered by an In -Network Provider located outside of Florida, you should notify us of inpatient admissions. How to Use Your Benefit Booklet 1-2 Section 2: What Is Covered? Introduction 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. Fvrh icinn- 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 for Ambulance 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: Air Ambulance 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. G11„ -;- 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. Dental Services Dental Services are limited to the following: 1. Care and stabilization treatment rendered within 90 days of an Accidental Dental Injury to Sound Natural Teeth. 2. Extraction of teeth required prior to radiation therapy when you have a diagnosis of cancer of the head and/or neck. 3. Anesthesia Services for dental care including general anesthesia and hospitalization Services necessary to assure the safe delivery of necessary dental care provided to you or your Covered Dependent in a Hospital or Ambulatory Surgical Center if: a) the Covered Dependent is under 8 years of age and it is determined by a dentist and the Covered Dependent's Physician that: i. dental treatment is necessary due to a dental Condition that is significantly complex; or ii. the Covered Dependent has a developmental disability in which patient management in the dental office has proven to be ineffective; or b) you or your Covered Dependent has one or more medical Conditions that would create significant or undue medical risk for you in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or Ambulatory Surgical Center. Exclusion: 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 2. Dental Implant. Diabetes Outpatient Self -Management Diabetes outpatient self -management training and educational Services and nutrition counseling (including all Medically Necessary equipment and supplies) to treat diabetes, if your treating Physician or a Physician who specializes in the treatment of diabetes certifies that such Services are Medically Necessary, are covered. In order to be covered, diabetes outpatient self -management training and educational Services must be provided under the direct supervision of a certified Diabetes Educator or a board -certified Physician specializing in endocrinology. Additionally, in order to be covered, nutrition counseling must be provided by a licensed Dietitian. Covered Services may also include the trimming of toenails, corns, calluses, and therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease. Diagnostic Services Diagnostic Services when ordered by a Physician are limited to the following: 1. radiology, ultrasound and nuclear medicine, Magnetic Resonance Imaging (MRI); 2. laboratory and pathology Services; 3. Services involving bones or joints of the jaw (e.g., Services to treat temporomandibular joint [TMJ] dysfunction) or facial region if, under accepted medical standards, such diagnostic Services are necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury; 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. Fvrh icinn- 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: 1. part-time (i.e., less than 8 hours per day and less than a total of 40 hours in a calendar week) or intermittent (i.e., a visit of up to, but not exceeding, 2 hours per day) nursing care by a Registered Nurse, 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). Fxrhminn- 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: 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 hype rparathyroidism; 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/healthresources. 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: 1. sterilization (tubal ligations and vasectomies), regardless of Medical Necessity; 2. surgery to correct deformity which was caused by disease, trauma, birth defects, growth defects or prior therapeutic processes; 3. oral surgical procedures for excisions of tumors, cysts, abscesses, and lesions of the mouth; 4. surgical procedures involving bones or joints of the jaw (e.g., temporomandibular joint [TMJ]) and facial region if, under accepted medical standards, such surgery is necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury; 5. 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 3 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). 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 5913- 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: 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. 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 clinical ecology; chelation therapy; thermography; mind -body interactions such as meditation, imagery, yoga, dance, and art therapy; biofeedback; prayer and mental healing; manual healing methods such as the Alexander technique, aromatherapy, Ayurvedic massage, craniosacral balancing, Feldenkrais method, Hellerwork, polarity therapy, Reichian therapy, reflexology, rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger -point myotherapy, and biofield therapeutics; Reiki, SHEN therapy, and therapeutic touch; bioelectromagnetic applications in medicine; and herbal therapies. Complications of Non -Covered Services, including the diagnosis or treatment of any Condition which is a complication of a non - covered Health Care Service (e.g., Health Care Services to treat a complication of cosmetic surgery are not covered). Contraceptive medications, devices, appliances, or other Health Care Services when provided for contraception, 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 your job 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 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 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. 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 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 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 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 to the Schedule of Benefits and consult with assignment of benefits may be required. your Physician to determine the most appropriate setting based on your health care and financial needs. When Services are rendered at an outpatient facility other than a Hospital there may be an out-of-pocket expense for the facility Provider as well as an out-of- pocket expense for other types of Providers. Assignment of Benefits to Providers Except as set forth in the last paragraph of this section, any of the following assignments, or attempted assignments, by you to any Provider will not be honored: • an assignment of the benefits due to you for Covered Services under this Benefit Booklet; • an assignment of your right to receive payments for Covered Services under this Benefit Booklet; or • an assignment of a claim for damage resulting from a breach, or an alleged breach of the terms of this Benefit Booklet. We specifically reserve the right to honor an assignment of benefits or payment by you to a Provider who: 1) is In -Network under your plan of coverage; 2) is a NetworkBlue Provider even if that Provider is not in the panel for your plan of coverage; 3) is a Traditional Program Provider; 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. 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, 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. 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 261h 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. 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. Enrollment Forms/Electing Coverage To apply for coverage, you as the Eligible Employee , Eligible Retiree must: 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; 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 Employee/Retiree and the employee's spouse under a legally valid existing marriage or Domestic Partner. 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 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. 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.: 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 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; 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 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. 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: 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 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. 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 Privilege 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. 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: i. 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 2 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. 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 Payer Provisions 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. 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 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. 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: 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 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. 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 Processinq 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 BCBSF/Monroe County BOCC and Health Care Providers 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. 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 nor Monroe County BOCC will be liable, whether in tort or contract or otherwise, for any acts or 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. 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. 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 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. 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 or judgment 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 etseq, 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 Affai rs. 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. Certified Registered Nurse Anesthetist 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. Condition means a disease, illness, ailment, injury, or pregnancy. Convenient Care Center 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 or jurisdiction 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/healthresources 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 Supplement to the Blue Options Benefit Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan 7t, Effective as of January 1, 2017 This is a supplement to the Blue Options Benefit Booklet (`Booklet") and is intended to provide information not otherwise included in the Booklet. In the event of a conflict between this Supplement and the Booklet, the provisions of this Supplement shall govern. In the event of a conflict between this Supplement and a County Resolution, the County Resolution shall govern. Table of Contents RESOLUTION NO.018-1998 - Domestic Partnerships Requirements.............................................3 RESOLUTION NO. 388-2013 - Retiree Eligibility Requirements........................................................6 RE -ENROLL ELIGIBILITY FOR FORMER EMPLOYEES RETIRING WITH FRS ..........................7 MEDICARE COORDINATION OF BENEFITS AFTER RETIREMENT....................................................7 OPTOUT................................................................................................................................................................... 7 InitialEnrollment Period............................................................................................................................... 7 OpenEnrollment Period................................................................................................................................7 CESSATIONOF ACTIVE WORK........................................................................................................................8 Insurance Coverage While on Leave of Absence..................................................................................8 Rehire/Reinstatement.................................................................................................................................... 8 ActiveMilitary Duty........................................................................................................................................9 CONTINUATIONOF COVERAGE......................................................................................................................9 EligibleRetirees.........................................................................................................................9 Surviving Spouses of Covered Retirees...................................................................................................9 DomesticPartners...........................................................................................................................................9 GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS......................................10 SELF -FUNDED PROGRAMS............................................................................................................................13 NON -TOBACCO USE POLICY..........................................................................................................................13 FALSE OR FRAUDLENT INSURANCE CLAIMS...........................................................................is CARRIERS AND CONTACT INFORMATION................................................................................16 2 w 0 0 w z w cc 0 RESOLUTION NO.081-1998 - DOMESTIC PARTNERSHIP Eligible Domestic Partner means an individual who meets the requirements of Resolution No. 081-1998 as restated below: 14.02 DEFINITIONS A. Domestic Partners. "Domestic Partners" are two adults who have chosen to share one another's lives in a committed family relationship of mutual caring. Two individuals are considered to be Domestic Partners if: 1. they consider themselves to be members of each others immediate family; 2. they agree to be jointly responsible for each other's basic living expenses; 3. neither of them is married or a member of another Domestic Partnership; 4. they are not blood related in a way that would prevent them from being married to each other under the laws of Florida; 5. each is at least of the legal age and competency required by Florida law to enter into a marriage or other binding contract; 6. they must each sign a Declaration of Domestic Partnership as provided for in Section 14.03 of Monroe County BOCC's Personnel Policies and Procedures Manual; 7. they both reside at the same address. B. Joint Responsibility for Basic Living Expenses. "Basic living expenses" means basic food and shelter. "Joint responsibility" means that each partner agrees to provide for the other's basic living expenses while the domestic partnership is in effect if the partner is unable to provide for him or herself. It does not mean that the partners must contribute equally or jointly to basic living expenses. C. Competent to Contract. "Competent to Contract" means the two partners are mentally competent to contract. D. Domestic Partnership. "Domestic Partnership" means the entity formed by two individuals who have met the criteria listed above and file a Declaration of Domestic Partnership as described below. E. Declaration of Domestic Partnership. "Declaration of Domestic Partnership" or "DDP" is a form provided by the Human Resources Director. By signing it, two people swear under penalty of perjury that they meet the requirements of the definition of domestic partnership when they sign the statement. The form shall require each partner to provide a mailing address. F. Dependent. "Dependent" means an individual who lives within the household of a domestic partnership and is: 1. A biological child or adopted child of a domestic partner; or 2. A dependent as defined under County employee benefit plan document. 3. A ward of a domestic partner as determined in a guardianship proceeding. G. Employee means an employee of the Board of County Commissioners, the constitutional officers or the Mosquito Control Board, except where the context is otherwise. 14.03 ESTABLISHING A DOMESTIC PARTNERSHIP A. An employee and his/her domestic partner as set out in Section 14.02 are eligible to declare a Declaration of Domestic Partnership (hereafter DPP) in the presence of the Human Resources Director, or the employee partner may present a signed and notarized DDP to the Human Resources Director. The DDP shall include the name and date of birth of each of the domestic partners, the address of their common household, and the names and dates of birth of any dependents of the domestic partnership, and shall be signed, under the pain and penalties of perjury, by both domestic partners and witnessed (two) and notarized. B. As further evidence of two individuals being involved in a domestic partnership, two of the following documents must be presented along with the DDP to the Human Resources Director: 1. A lease, deed or mortgage indicating that both parties are joint responsible; 2. Driver's licenses for both partners showing same address; 3. Passports for both partners showing the same address; 4. Verification of a joint bank account (savings or checking) 5. Credit cards with the same account numbers in both names; 6. Joint wills; 7. Powers of attorney; or 8. Joint title indicating both partners own a vehicle. C. An individual cannot become a member of a domestic partnership until at least six months after any other domestic partnership of which she or he was a member has ended and a notice that the partnership has ended was given as provided for in Section 14.04. This does not apply if their domestic partners are deceased. D. Domestic partners may amend the DDP to add or delete dependents or change the household address. Amendments to the DDP shall be executed in the same manner as the declaration of a domestic partnership. 14.04 TERMINATION OF A DOMESTIC PARTNERSHIP A. A domestic partnership is terminated when: 1. one of the partners dies; 2. one of the partners marries; or 3. a domestic partner files a termination statement with the Human Resources Director. A domestic partnership may be terminated by a domestic partner who files with the Human Resources Director by hand or by certified mail, a termination statement. The person filing the termination statement must declare under pain and penalties of perjury that the domestic partnership is terminated and that a copy of the termination statement has been mailed by certified mail to the other domestic partner at his or her last known address. The person filing the termination statement must include on such statement the address to which the copy was mailed. B. The termination of a domestic partnership shall be effective immediately upon the date of a domestic partner. The voluntary termination of a domestic partnership by a partner shall be effective thirty (30) days after the receipt of a termination .19 statement by the Human Resources Director. If the termination statement is withdrawn before the effective date, the domestic partner shall give notice of the withdrawal, by certified mail, to the other domestic partner. C. If a domestic partnership is terminated by the death of a domestic partner, there shall be no required waiting period prior to filing another domestic partnership. If a domestic partnership is terminated by one or both domestic partners, neither domestic partner may file another domestic partnership until six (6) months have elapsed from effective termination. D. It is the obligation of the employee domestic partner to notify the Human Resources Director of the termination of a domestic partnership as soon as possible after it occurs. 14.05 HUMAN RESOURCES DIRECTOR RECORDS A. The Human Resources Director will keep a record of all employees DDP's, Amendments and Termination Statements. The records will be maintained so that DDPs, Amendments and Termination Statements will be filed to which they apply. B. The Human Resources Director shall indentify on the DDP what type of documents was presented for further verification of the domestic partnership. C. Upon determination by the Human Resources Director that the DDP is complete and that further evidence of the domestic partnership has been presented as provided in Section 14.03(B); the Human Resources Director shall provide the employee with a copy of the DDP. The employee/domestic partner shall become eligible to elect domestic partnership health and other employee fringe benefits as provided in Section 14.06. It will be the employee's responsibility to notify the Employee Benefits Section of their intent to enroll the domestic partner and/or any eligible dependents under the Monroe County Employee Benefit Plan. Domestic partner/dependents enrolled in the Monroe County Employee Benefit Plan are subject to the same rules and provision applicable to covered spouses/dependents. D. The Human Resources Director shall provide forms to employees requesting them. E. The Human Resources Director shall allow public access to domestic partnership records to the same extend and in the same manner as any other public record. RESOLUTION NO.388-2013 - RETIREMENT ELIGIBILITY FOR GROUP HEALTH PLAN Eligible Retiree means an individual who meets one of the following requirements as established by the Board of County Commissioners Resolution No. 388-2013 - Retirement Eligibility Requirements for Group Health Insurance Coverage for Monroe County Employees: • Hire date prior to 10/01/01; a minimum of ten (10) years of full-time service with Monroe County; retire under the FRS on, or after, the Normal Retirement date as described in Section 121.021(29), F.S.; and covered under the Plan at retirement. Current contribution is $5.00 per month for each year of creditable service with the Florida Retirement System at the time of retirement with Monroe County. Premium minimum is $50 for ten years of service and the premium maximum is $150 for 30 years of service. • Hire date prior to 10/01/01; a minimum of ten (10) years of full-time service with Monroe County; retire under the FRS at an Early Retirement date as described in Section 121.021(30), F.S.; covered under the Plan at retirement; 60 years of age or age and years of service must satisfy Rule of 70** at time of retirement. Current contribution is $5.00 per month for each year of creditable service with the Florida Retirement System at the time of retirement with Monroe County. Premium minimum is $50 for ten years of service and the premium maximum is $150 for 30 years of service. • Hire date prior to 10/01/01; a minimum of ten (10) years of full-time service with Monroe County; retire under the FRS at an Early Retirement date as described in Section 121.021(30), F.S.; covered under the Plan upon retirement; NOT 60 years of age and age and years of service do not satisfy Rule of 70**. Current contribution is the departmental rate. Upon attaining either the age of 60 or satisfy Rule of 70** the contribution will change to the current contribution of $5.00 per month for each year of creditable service with the Florida Retirement System at the time of retirement with Monroe County. Premium minimum is $50 for ten years of service and the premium maximum is $150 for 30 years of service. Hire date on or after 10/01/01; a minimum of ten (10) years of full-time service with Monroe County; retire with the FRS as described in Section 121.021(29 or 121.021 (30), F.S.; covered under the Plan upon retirement. Current contribution is departmental rate. Retire from FRS as described in Section 121.021(29) or 121.021(30), F.S.; less than ten (10) years of full-time service with Monroe County; covered under the Plan upon retirement. Current contribution is the departmental rate. Former Eligible Employee with at least ten (10) years of full-time service with Monroe County; covered under the Plan upon termination of employment and fully vested under FRS who elect not to retire under FRS upon termination of employment with Monroe County, may elect to re -enroll under the Plan upon retirement under FRS, provided that Monroe County was their last FRS employer. Current contribution is the departmental rate. *HIS: Health Insurance Subsidy per Section 112.363, Florida Statutes. **Rule of 70: Eligible Retirees satisfy the Rule of 70 if their age, combined with the number of years of service with Monroe County, totals 70 or more. R RE -ENROLL ELIGIBILITY FOR FORMER EMPLOYEES RETIRING WITH FRS Former Employee Retiring with FRS - An individual who meets the eligibility criteria specified below is an Eligible Retiree and is eligible to apply for coverage under the Blue Options Benefit Booklet for Covered Monroe County Group Health Participants: A person who elects to continue re -enroll in the Monroe County Group Health Plan at the time of their official retirement under the Florida Retirement System (FRS), and is not currently an Eligible Employee but Monroe County was their last FRS employer prior to retirement. Coverage will be offered within 30 days of retirement. If the Eligible Retiree fails to elect retiree coverage at time of retirement, waives retiree coverage or lets coverage lapse, the Eligible Retiree will permanently lose entitlement to re -enroll under the Monroe County Group Health Plan. MEDICARE COORDINATION OF BENEFITS AFTER RETIREMENT Retirees, their eligible dependents, or a surviving spouse who becomes eligible for Medicare due to age 65, End state Renal Disease (ERSD), or disability must notify the Monroe County BOCC Benefits Office immediately. It is the responsibility of the ensured to enroll in Medicare as soon as they are eligible. Medicare will become the Primary Payer and coverage under the Monroe County Health Plan will become the Secondary Payer. The Monroe County BOCC will not be liable to any individual covered under this health plan on account of any nonpayment of primary benefits resulting from failure to be timely notified by the enrolled participant of their eligibility for enrollment in Medicare. OPT OUT Initial Enrollment Period means the 30 day period starting on your date of hire during which you and your eligible dependent(s) have the ability to either elect coverage for yourself and/or your eligible dependents, or Opt Out of coverage. You can Opt Out by indicating that you elect to waive coverage on the Monroe County Benefits Enrollment Form. If you Opt Out during your Initial Enrollment Period, you will not be able to enroll in the Monroe County Group Health Plan unless you have a Special Enrollment right or during a future Open Enrollment Period. Open Enrollment Period means the period selected by Monroe County during which you can elect coverage for yourself and/or your eligible dependents, or Opt Out of coverage, for the immediately following Plan Year. You can Opt Out by indicating that you elect to waive coverage on the Monroe County Benefits Enrollment Form. If you Opt Out during the Open Enrollment Period, you will not be able to enroll in the Monroe County Group Health Plan unless you have a Special Enrollment right or during a future Open Enrollment Period. 7 CESSATION OF ACTIVE WORK - Insurance Coverage While on Leave of Absence The Plan will continue to maintain group insurance benefits for employees while on approved paid leave status. MEDICAL LEAVE - If an Eligible Employee ceases Active Work due to illness, injury or pregnancy the Employer in its sole discretion may approve a medical leave of absence. Coverage for the Eligible Employee will continue under the Plan, but for no longer than six (6) months from the date the approved medical leave begins, including any approved FMLA leave. Coverage of Eligible Dependents will continue during this time provided required premiums are continued to be paid. Notification of all approved medical leave must be provided to the Monroe County Group Health Plan Administrator (Benefits Office) by the Employer. The notification should contain the date on which the leave began and when it will end. An Eligible Employee who has been on an approved medical leave must return to active work for a minimum of 30 days after the approved medical leave ends. In the event an Eligible Employee on an approved medical leave does not return to active work at the end of the leave, the Eligible Employee will be required to reimburse the Plan for the health benefit premiums paid during the leave to continue coverage. *EXCEPTION: When an Eligible Employee fails to return to active work because of the continuation, recurrence, or onset of either a serious health condition of the Eligible Employee or an Eligible Employee's family member the Plan will not recover the health benefit premium payments made on the Eligible Employee's behalf during the approved medical leave. The Monroe County Group Health Plan Administrator (Benefits Office) may require medical certification of the Eligible Employee's or the Eligible Employee's family member's serious health condition. If leave extends beyond the maximum allowed period of six months and the employee is on a non -paid status, said employee must make the monthly premium payments for themselves in order to continue health insurance coverage. Failure to make payment(s) on a timely basis will result in termination of coverage. PERSONAL LEAVE — If personal leave without pay is approved by the Employer, said employee must reimburse the Plan for the health benefit premiums paid during the leave to continue coverage. Coverage of Eligible Dependents will continue during this time provided required premiums are continued to be paid. Personal Leave under the Plan cannot exceed six (6) months Rehire/Reinstatement If subsequent to termination of coverage an Eligible Employee is rehired or reinstated as an Eligible Employee the Eligible Employee must meet the eligibility requirements in the Eligibility for Coverage section. However, the Plan allows a grace period of 2 days following the date of termination of coverage during which an Eligible Employee may be rehired or reinstated without penalty. N. Active Military Duty Return from active military duty by a former Eligible Employee of two weeks or longer who is rehired or reinstated will be treated as if the Eligible Employee were on an approved leave of absence for purposes of eligibility under the Plan. The Plan's waiting period or preexisting condition exclusion period will not be applicable CONTINUATION OF COVERAGE Eligible Retirees: If any Eligible Retiree fails to elect retiree coverage at time of retirement, waives retiree coverage or lets coverage lapse, the Eligible Retiree will permanently lose entitlement to re -enroll under the Monroe County Group Health Plan. Surviving Spouses of Covered Retirees: Upon the death of a Covered Retiree, the Surviving Spouse may continue coverage under the Monroe County Group Health Plan provided: (1) the Surviving Spouse does not remarry; and (2) the Surving Spouse makes timely payment of any required contribution. It is the sole responsibility of the Surviving Spouse to notify the Monroe County Group Health Plan Administrator (Employee Benefits Office) of a change in marital status. Domestic Partners: For purposes of COBRA Continuation Coverage Rights, a Domestic Partner of an Eligible Employee shall be treated as the Eligible Employee's "spouse" and the dependent child(ren) of a Domestic Partner shall be treated as the Eligible Employee's stepchild(ren). I GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS Introduction You're getting this notice because you recently gained coverage under a group health plan (Monroe County Group Health Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan's Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse's plan), even if that plan generally doesn't accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you're an employee, you'll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you're the spouse of an employee, you'll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse's hours of employment are reduced; • Your spouse's employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent -employee dies; • The parent -employee's hours of employment are reduced; 10 The parent -employee's employment ends for any reason other than his or her gross misconduct; The parent -employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a "dependent child." i Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a i qualifying event. If a proceeding in bankruptcy is filed with respect to the Monroe County Board of County Commissioners, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee's spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. i i I- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee's becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after the qualifying event occurs. You must provide this notice to: Maria Fernandez -Gonzalez, Benefits Administrator, 1100 Simonton Street, Suite 2-268, Key West, FL 33040; Facsimile (305) 292-4452. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. 11 *NOTE: The disability_ would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. A copy of the letter from Social Security with the date disability was determined and approved must be provided this to: Maria Fernandez -Gonzalez, Benefits Administrator, 1100 Simonton Street, Suite 2-268, Key West, FL 33040; Facsimile (305) 292-4452. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse's plan) through what is called a "special enrollment period." Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healtheare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) For more information about the Marketplace, visit www.HealthCare .00v. Keep your Plan informed of address changes To protect your family's rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information You can obtain information about the Monroe County Group Health Plan and COBRA from: Natalie Maddox, Coordinator 1100 Simonton Street, Suite 2-268 Key West, FL 33040 Phone: 305-292-4450 Email: maddox-natalie@monroecounty-fl.gov 12 SELF -FUNDED PROGRAMS Where the Board of County Commissioners has determined that the use of a self -funded program is in its best interest, it will be the County Administrator's responsibility to oversee the Administration of said programs. Any proposed change to the self -funded health insurance program that would constitute a material reduction in benefits or change in cost to current employees and retirees that will be presented to the Board of County Commissioners will be preceded by a two week written notice to the affected employees and retirees. NON -TOBACCO USE POLICY Monroe County BOCC has implemented a non -tobacco use policy for all newly enrolled Medical Health plan members effective January 1, 2015. All Newly Enrolled individuals in the Medical Health Plan will be assessed a surcharge if currently using tobacco products. Tobacco products are defined as cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip, electronic or e-cigarettes that contain nicotine or any other product that contains tobacco or nicotine. Nicotine replacement products, such as gum and patches, are also considered tobacco products. Tobacco user Surcharge & Penalty 1. The non -tobacco use policy applies to employees and their dependents enrolled in the medical health and prescription benefit plans. Enrolled employees are required to complete the Tobacco Use Attestation Certification form within 30 days of enrollment. Failure to complete and return the Tobacco Attestation Certification form will be treated as an admission that the employee is a tobacco user. 2. Each newly covered dependent(s) over the age of 18 must complete the Tobacco Use Attestation form before dependent coverage becomes effective. 3. Changes in the use of tobacco products by anyone covered in the plan require the immediate completion of a new certification form. 4. Discontinuing the use of tobacco products requires a new non -tobacco user certification. 5. Using tobacco products requires a new tobacco user certification. 6. All certification forms must be submitted to the BOCC Group Benefits office. 7. Tobacco users will be charged a monthly surcharge of $50 each per month. 8. Failing to certify or providing false information will result in a $50 surcharge and a penalty of $50 each per month (Total $100 each per month). 13 9. Nonrefundable surcharges and/or penalties for the employee and/or dependents will be deducted from the employee's next paycheck in accordance with the payroll schedule. 10. Changes to the surcharge and penalties will be processed by the group benefits office in accordance with the employer's next payroll schedule. 11. In the absence of a completed Non -Tobacco use Attestation Certification Form, the surcharge will be assessed. 12. Please obtain the Tobacco use Attestation Certification form from the group benefits office. The BOCC Group Health Plan is committed to helping you achieve your best health. The ability to avoid the Tobacco Use Surcharge is available to all employees. If you think you might be unable to meet a standard to avoid the Tobacco Use Surcharge, you might qualify to avoid the surcharge by different means. Contact the group benefits office and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. 14 Important Notice about False or Fraudulent Insurance Claims As the sponsor of a medical insurance plan, Monroe County is an "insurer" when it comes to the medical insurance plan offered to you and other eligible employees. You should understand that insurance fraud is a punishable crime under Florida law. Fraud occurs when you or a provider intend to injure, defraud or deceive an insurer. Fraudulent acts can include such things as: • Presenting any written or oral statement as part of or in support of a claim for payment, knowing that such statement contains any false, incomplete or misleading information. • Knowingly concealing information concerning any fact material to an application for insurance. • Agreeing with a service provider other than a hospital to waive deductibles or copayments when the service provider will bill the County's medical plan for its usual and customary charges. • An individual being charged for procedures that weren't performed. • A Provider making it a practice to waive all coinsurance responsibility or deductibles for certain procedures on patients. In addition to fraud being a crime, you should understand that fraudulent claims have an adverse impact on the costs of the County's medical plan. Since the medical plan is funded by the County and its employees and retirees, false or fraudulent claims result in higher premium amounts for you and your co-workers, retirees, and the County. The Florida Statute regarding False or Fraudulent Insurance Claims can be found at Florida Statutes 817.234. The Benefits Office will provide you with a copy of the statute upon written request at no charge. HOW TO RESPOND TO IMPROPER CHARGES OR SUSPECTED FRAUD • If you believe that there is an issue with the billing or an EOB (Explanation of Benefits), you should contact BCBSFL Customer Service at (800) 664-5295. • If you believe there has been an improper charge(s) on your bill after you receive the EOB (Explanation of Benefits) from BCBSFL and the EOB does not show that the charge(s) was corrected, you should contact the doctor (or their billing office) to correct the issue first and if the issue is not resolved, you should contact Employee Benefits at 305-292-4446. To report suspected insurance fraud or abuse, you should complete the form located on the BCBSFL website: http://www3.bcbsfl.com/wps/portal/bcbsfl/aboutus/reportfraud . The Benefits Office will provide you with a copy of the form upon written request at no charge. Individuals can also contact the Special Investigation Unit at 1-888-237-1501. 15 CARRIERS AND CONTACT INFORMATION: Medical Benefits (Administered by Blue Cross Blue Shield of Florida) Toll -Free Customer Service: (800)664-5295 Website: floridablue.com Prescription Drug Benefits (Administered by Envision Rai) Toll -Free Customer Service: (800) 361-4542 Website: www.envisionrx.com Vision Benefits (Insured and Administered by Vision service Plan Insurance Company) Toll -Free Customer Service: (800) 877-7195 Website: www.vsp com Dental Benefits (Insured and Administered by Delta Dental Toll -free Customer Service: (800) 521-2651 Website: www.deltadentalins.com Group Life, Accidental Death and Dismemberment, and Supplemental Life (Insured by Minnesota Life Insurance Company, A Securian Financial Group Affiliate) (Administered by Ochs, Inc.) Toll -Free Life and AD&D Claims: (888)658-0193 Toll -Free Group & Supplemental Life Customer Service: (800)392-7295 Email: ochs@ochsinc.com Employee Assistance Program (Administered by Quantum Health Solutions of Florida) Toll -Free Customer Service: (877)747-1200 Services Available: 24 Hours Per Day/365 Days Per Year 16 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o:o 000 0 00 0 00 0 00 00 0 0 00 0 00 0 00 0 o o 0 0 0 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 000'oo'o o'o o'o'o o'o'o o:o 'o o'o'o o'o'o o'o'o'd' o o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 0 0 0 Q( oN oN oN a�'. n Sy o o o Q o o o a�'. n Sy o o o Q o LL Q Q (n O Z 0 LL Q Q (n O Z 0 LL ~ fi r m rn r m uP ro o c+ O m o ro N m m v rn m o co co � r N o o o N m y •• u� :..co v •• ai m rn m o o o M co '..�. r 0,. � .9 O .o. co mIm : ui. ai ro : co W N : co o. o o loly 0 rn m co � u� co o r m rn m co co co LL� O O m V (O U3 N W N (O U3 � O � - N rn rn m r o o v o 0 0 0, N o N, o r m v co m': of ai m co N '+� r <» <» <» <» co <» <» o co ^Fi m co o _^ o 0 0 o o o o m co co orn 0 O O O O O O O O m N co :r ri N co :o N.o O o:ro o oo <c <» <» <» <» <» <» n It LL7N 16O O O O O O Cl :..m N c' � V o o o 0 0 0 o co m ro ^o ro rn o o 0 0 rn o o o o o ro' o co co co o v co o rn m o v u� u� m o co rn rn r u� n N O O O M O r m: m co u� m co m co v m rn N m - m r m N m uo ro fA `: fA fA : fA fA fA : fA fA : fA fA fA : fA N olo 000 0 0'0 0 0''.0 0 0l0 0 0'.o A j: N N S N O Z 0 ll Q Q (n O Z 0 LL ~ 0 0 o 0 00 0 0 o 0 0 o 0 0'0 0 0 o 0 0 o 0 0 o o o vv 0 0 o 0 0 0 0 0 o 0 0 o 0 0 o 0 0 o 0 0 0 0 0 0 0 o v v 0 00 00 0 o rom,v U3 U3 U3 U3 U3 U3 U3 N N sn O O O O O O N N N f0 O O O O of LL� O W r V N M N V V O O O N N O W O O OD O O O V O W U3 U3 U3 N O N V I� W M - N N o o 0 0'0 0 0 o 0 0 o 0 0 o 0 0 vv o o 0 0 o 0 0 o 0 0 o 0 0 0 0 o v v o o o o o 0 0 0 0 0 0 0 0 0 o m m v o <. o. oloo:o olo o:o to o:olo o: Im : in of O: of oolo olo Olo to Ololo orro lrlui U3 U3 U3 : U3 U3 U3 U3 : U3 U3 U3 : U3 U3 U3 : U3 U3 o o 0 0 0 0 0 o 0 0 o O O o N c! p O O O O O O O O O O O O O O N N f0 o:o 000 0 00 0 00 o ro� mro r v olo: olo o:o olo o:o to orlu� r:u�l :ro of 0: olo olo olo Olo to O roilco r>oi Ivin N M N V V O O O O O O O O O O O N N D7 W O O OD O O O O O O O O O O O V D7 W 0 l 0 0 l 0 0 ': 0 0 l o O ': o t o r ':. m. oil m U3 - - - - - - - - - U3 N D7 N V r W m. : W -m N I I I roSvly f� l<»Iv N O O O O r m (O (O M M N LL� D7 O M O V O `. 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