Item C19C oun t y of Monr
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BOARD OF COUNTY COMMISSIONERS
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Mayor David Rice, District 4
The Florida Ke s lv ',
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Mayor Pro Tern Sylvia J. Murphy, District 5
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Danny L. Kolhage, District 1
George Neugent, District 2
Heather Carruthers, District 3
County Commission Meeting
December 13, 2017
Agenda Item Number: C.19
Agenda Item Summary #3678
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez - Gonzalez (305)
292 -4448
n/a
AGENDA ITEM WORDING: Approval to advertise a Request for Proposals for Fully Insured
Medical Plans (without Pharmacy Benefits), including Claims Administration, Case Management
and Utilization Review Services, Disease Management (DM), Network Management, Wellness
Programs, and other Related Services.
ITEM BACKGROUND: On February 15, 2017, The County Commission requested that in 2017-
2018 staff issue two health insurance Requests for Proposals. The first was an RFP for Fully Insured
Medical Plans and the second was an RFP for a Self- Funded Plan. Before you today is the approval
to advertise the Fully Insured Medical Plan (without Pharmacy Benefits).
PREVIOUS RELEVANT BOCC ACTION:
March 2010 BOCC directed staff to rebid for Fully- Insured and Self- Funded Providers.
February 2011 BOCC approved the RPF for services in medical plan administration on a Self -
Funded or Fully- Insured basis.
March 2011 was bid opening for medical plan administration on a Self- Funded or Fully- Insured
basis. No Fully- Insured proposals were received.
February 15, 2017 — BOCC directed staff to issue the Fully insured health insurance program RFP,
Agenda Item 2642 attached.
CONTRACT /AGREEMENT CHANGES:
n/a
STAFF RECOMMENDATION: Approve
DOCUMENTATION:
MCBCC Fully Insured Medical RFP Draft 2018 ch 11.20.2018 without comment.. —
EXHIBIT A - SCOPE OF SERVICES
EXHIBIT B - MEDICAL QUESTIONNAIRE
EXHIBIT C - NETWORK DISRUPTION
EXHIBIT D - BENEFIT COMPARISON
EXHIBIT E - RATE EQUIVALENTS
EXHIBIT F - PRICING EXHIBIT
ATTACHMENT A - MEDICAL PLAN BOOKLET (003)
Agenda Item 2642 - February 15 2017
FINANCIAL IMPACT:
Effective Date: N/A
Expiration Date: N/A
Total Dollar Value of Contract: N/A
Total Cost to County:
Current Year Portion:
Budgeted:
Source of Funds:
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing:
Grant:
County Match:
Insurance Required:
Additional Details:
If yes, amount:
I "IXTAl IHIlWa,
Bryan Cook
Completed
Cynthia Hall
Completed
Assistant County Administrator Christine Hurley
11/28/2017 3:50 PM
Budget and Finance
Skipped
Maria Slavik
Skipped
Kathy Peters
Completed
Board of County Commissioners
Pending
11/28/2017 3:20 PM
11/28/2017 3:47 PM
Completed
11/28/2017 2:54 PM
11/28/2017 2:54 PM
11/28/2017 4:18 PM
12/13/2017 9:00 AM
MONROE COUNTY
REQUEST FOR PROPOSALS
FOR
FULLY INSURED MEDICAL PLANS
WITHOUT PHARMACY BENEFITS
CLAIM ADMINISTRATION, CASE MANAGEMENT AND
UTILIZATION REVIEW SERVICES, DISEASE MANAGEMENT
(DM), NETWORK MANAGEMENT, WELLNESS PROGRAMS,
AND OTHER RELATED SERVICES
BOARD OF COUNTY COMMISSIONERS
Mayor, David Rice, District 4
Mayor Pro Tern, Sylvia J. Murphy, District 5
Danny L. Kolhage, District 1
George Neugent, District 2
Heather Carruthers, District 3
COUNTY ADMINISTRATOR
Roman Gastesi
CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES
DEPARTMENT
Kevin Madok Employee Benefits
Issuance Date: December 18, 2017
Bid Opening: February 19, 2018
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TABLE OF CONTENTS
SECTION ONE - INSTRUCTIONS TO PROPOSERS
SECTION TWO - COUNTY FORMS
EXHIBITS: EXHIBIT A
EXHIBIT B
EXHIBIT C
EXHIBIT D
EXHIBIT E
EXHIBIT F
SCOPE OF SERVICES
MEDICAL QUESTIONNAIRE
NETWORK DISRUPTION
BENEFIT COMPARISON
CPT CODE WORKSHEET
PRICING EXHIBIT
ATTACHMENTS: A. 2017 MEDICAL PLAN BOOKLET
B. MEDICAL CLAIMS, LAG, AND ENROLLMENT BY MONTH
C. LARGE LOSS REPORT — MEDICAL
D. CENSUS
E. RATE EQUIVALENTS
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SECTION ONE: INSTRUCTIONS TO PROPOSERS
1. Objective of the Request for Proposals (RFP)
The Monroe County Board of County Commissioners wishes to receive and evaluate
competitive proposals for Fully Insured Medical Benefit Plans, as replacements for its 'current
Self- insured Medical Benefits Plans. The services to be provided include but are not limited to:
claim administration, case management, utilization review services, Disease Management (DM),
network management, wellness programs, and other related services as set out in the Scope of
Services — Exhibit "A ".
The County currently offers a custom PPO, and an HDHP to active employees and non-
Medicare retirees. In addition, they offer a Medicare retiree only plan with an EGWP and
separate MOOP amounts for RX and Medical. 'Proposers must quote using the County's
Carved out Pharmacy Benefits' Program. The ,County ,is requesting proposals to evaluate
several alternatives, including,:.
• Option 1 PPO Design for the Existing 'Plan 03559 (Mandatory)
• Option 2 — PPO or POS'High Deductible Health Plan as outlined (Mandatory)
• Option 3 — HMO' Design', using the Existing In Network Plan 03559 Benefits
• Option 4 — HMO' Design' based on the existing HDHP plan..
• Option 5 — Medicare Retiree Only PPO with EGWP and split MOOP amounts
(Mandatory)
• Option 6 — Medicare Retiree Only HMO' Design' based on the Retiree PPO with EGWP
and split MOOR
It is important to the County to evaluate the insured premium of the Medical Proposals based on
the current programs as similar as possible. Therefore, while there is flexibility in the ability of
each proposer to offer benefits that they believe offer the greatest benefit value for the County, it
is mandatory that each proposer provide rates and benefits that match the Current Benefit
Programs (Options 1, 2 and 5).
In addition to the three (3) Mandatory Options, the proposers are requested to loffer your closest
alternatives for the HMO Options outlined..
The County currently contracts with EnvisionRx for Pharmacy Benefit Management Services.
This contract is being renewed as of January 2018.
PPACA requires the County to integrate the pharmacy claims with the medical claims to
calculate maximum out of pocket amounts for participants. Special consideration will be given
to proposals that will allow the County to contain costs, maintain integration of the medical
and pharmacy claim data, and provide medical benefits that most closely match the current
benefit design.
It is critical to the County that the overall medical plan is well coordinated and effective in
the delivery of services to its employees, retirees, and their dependents. Proposers must
demonstrate that they can effectively coordinate with other service providers, assure that
they can integrate necessary data, and clearly outline what the administrative cost of this
integration will be.
The County anticipates that this contract will be awarded for an effective date of
January 1, 2019. The County desires an initial contract term of thirty six (36) months
and the County may elect to renew for up to two (2) additional consecutive 1 year
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terms. The contract term will be dependent upon the acceptability of premium
guarantees, coverage, service, provider stability and market conditions.
The County is requesting Proposals for Fully Insured Medical plans only with the
following consideration:
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,
with the amount of compensation, broker's name, address and the company they are
representing, 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
NOTICE OF POSSIBLE INTERVIEW
The County may wish to interview finalists in Key West on April 25 and April 26 tH ,
2018. Proposers who are to be invited for finalist interviews will be notified no
later than April 18, 2018 (specific instructions regarding the presentation will also
be provided no later than April 18, 2018) 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
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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. Plan benefits are shown in Attachment A
and a Benefit Comparison Grid is provided as Exhibit D. Monroe County added a High
Deductible Health Plan and made several modifications to their existing benefits
(highlighted in Exhibit D) to their offering on January 1, 2018. 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 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.
Domestic Partners are included as dependents subject to the criteria in Monroe
County's policy (Monroe County Resolution No, 081 - 1998
Active participant (along with their dependents) premiums are deducted bi- weekly and
retiree /surviving spouses and COBRA premiums are paid on a monthly basis. All
invoices are paid monthly.
Contribution rates for the Fiscal Year 2017/2018 are included in Attachment E + Rate
Equivalents. Rates do not include commissions.'
The current plan is administered by Florida Blue, which has provided coverage since
2011. With the Implementation of Florida Blue as the TPA, the County achieved
savings in their claims costs of over $5.7 million over the first 12 months of the contract.
They are 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.
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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 medical administration program currently includes the following provisions:
• Coordination of Benefits
• Subrogation /Right of Reimbursement
• Pre - Admission Certification
• Prior authorization for certain procedures
• Care Coordination for facility admissions
• Care Consultants: one -to -one support and guidance with health care needs
• Condition Management for medical conditions
• 24x7 nurse line for questions
• Prenatal health management program
• Diabetes health management program
• Clinical prior authorization for certain physician or facility administered
medications
• Onsite biometric screening for all participants with outreach as warranted
• Onsite presentations on health related topics /conditions
• Wellness program contributions and consultants to help design programs
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.
Network disruption analysis — higher points will be
granted according to the higher percentage of
participating providers as compared to Exhibit C —
Network Disruption.
20 points
PPO Network accessibility for all participants —
10 points
higher points will be assessed for vendors having the
higher percentage match for the total population.
Overall costs
55 points — awarded
based on the following
• Total Premium
criteria.
• Rate guarantees or Rate Increase maximums
• Initial premium/
over multiple years 3 years preferred
plan costs 40
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The consultants are paid a fee from the County for these services and are not eligible to
receive additional compensation or commission from any proposer, vendor, or to submit
a proposal on behalf of any agency, broker, or carrier with regard to this RFP
• Contributions for Wellness programs
points
• Pricing guarantees
10 points
• Wellness
Contributions 5
p oints
Ability to provide the Scope of Services. The points
20 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:
• Qualifications of Proposer and staff; availability of
staff
• Types and description of programs offered:
Disease Management, Case Management,
Utilization Review, Wellness Programs, Network
Management, etc.
• Performance guarantees, including the amount of
premium at risk and the methodology for
calculating whether the guarantee has been met.
Compliance with RFP Specifications (responsiveness,
5 points
submission of required forms, follows required format,
etc.
Prior experience with government clients
5 points
Location of firm (local preference if applicable: up to 5
5 points
additional points
Total points earned are on a scale of 1 —120 points
1 = lowest 120 = highest
A Selection Committee will be analyzing Proposals 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
Key West, Florida 33040
Facsimile (305) 292 -4452
All requests for additional information must be received no later than 3:00 PM, January
10, 2018 Any requests received after that date and time will not be answered. All
requests for additional information will be answered via an addendum to the RFP, which
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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 (INSTRUCTIONS)
The Proposal submitted in response to this Request for Proposals (RFP) shall be
printed on 8 -1/2" x 11" white paper and bound; shall be clear and concise, tabulated,
and provide the information requested herein. Statements submitted without the
required information will not be considered. Responses shall be organized as
indicated below. The Proposer should not withhold any information from the written
response in anticipation of presenting the information orally or in a demonstration, since
oral presentations or demonstrations may not be solicited. Each Proposer must submit
adequate documentation to certify the Proposer's compliance with the County's
requirements. Proposer should focus specifically on the information requested.
7. Format.
The Proposal shall include the following:
A Cover Page_
A cover page that states "Request for Proposals for Fully Insured Medical Plans ". 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 —Include tabs and page numbers for all materials
C. Tabbed Sections
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 must be willing to offer the Medical benefits in conjunction with a
carved out Prescription Drug benefit.
• The Proposer shall be licensed in the State of Florida to provide the requested
services and provide evidence of such license.
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• The Proposer must provide evidence that they meet the State of Florida Office
of Insurance Regulation's financial and reserve requirements.
• 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 Fully Insured Medical Plan Services 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:
• Name and full address of the client;
• Name, address, title, and telephone number of the client contact;
• 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 your completed Exhibit A — Scope of Services under this Tab.
If your response indicates that you "can comply with deviations ", you must fully explain
the deviations in this Tab.
Tab 4. Questionnaire and Cost Proposal
Please include the completed Questionnaire (Exhibit B) under this tab in the file format
as provided in the RFP package. Responses should be succinct while providing
sufficient information to reply to the specific question.
Excessive language or wording is not desired.
All Premiums and /or Fees for the services described in this RFP shall be included in
EXHIBIT F - Pricing Exhibit. The total fee shall be an all- inclusive cost for the services
proposed. The fees should match the rate structure outlined in the pricing Exhibit. No
additional costs or fees will be paid, including but not limited to travel costs, per diems,
telephone charges, facsimile charges, and postage charges.
It is not anticipated that contingencies will be included in the Proposal. However, please
include your underwriting assumptions under this Tab, immediately after the Pricing
Exhibit.
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Tab 5. Staffing for this Project and Qualifications of Key Personnel
The Proposer shall 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 6. Other Information
Tab 6 shall include:
• Exhibit C — Network Disruption;
• Exhibit D — Benefit Comparison;
• Exhibit E — CPT Code Worksheet;
• GeoAccess Reports;
• Excel List of PPO network providers as described in Question 6 of
the Provider Networks Section of the Questionnaire;
• Deviations to the RFP not provided elsewhere.
• Sample financial and claim reports
• Sample Policy
Proposer shall provide any additional project experience not already
described in other tabs that will give an indication of the Proposer's overall
abilities.
If the Proposer cannot fully comply with any of the terms contained
in the Request for Proposals, all deviations to the terms must be
spelled out in this section, i.e. Tab 6.
Tab 7. 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
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(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
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 8. 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 8:
Forms:
• Submission Response Form
• Lobbying and Conflict of Interest Ethics Clause
• Non - Collusion Affidavit
• Drug Free Workplace Form
• Public Entity Crime Statement
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• 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, nine (9) complete copies of the Proposal, and two (2)
complete copies on CD or other electronic media, in a sealed envelope, clearly marked
on the outside with the Proposer's name and " PROPOSAL FOR FULLY INSURED
MEDICAL PLANS WITHOUT PHARMACY BENEFITS ", 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. local time on February 19, 2018.
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. 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
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may not transact business with any public entity in excess of the threshold
amount provided in Section 287.017, Florida Statutes, for CATEGORY
TWO for a period of 36 months from the date of being placed on the
convicted vendor list. Category Two: $25,000.00
C. DRUG -FREE WORKPLACE FORM: Any person submitting a bid or
proposal in response to this invitation must execute the enclosed DRUG -
FREE WORKPLACE FORM and submit it with his /her proposal. Failure to
complete this form in every detail and submit it with the bid or proposal
may result in immediate disqualification of the bid or proposal.
D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any
person submitting a bid or proposal in response to this invitation must
execute the enclosed LOBBYING AND CONFLICT OF INTEREST
CLAUSE and submit it with his /her bid or proposal. Failure to complete
this form in every detail and submit it with the bid or proposal may result
in immediate disqualification of the bid or proposal.
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.
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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 FULLY INSURED MEDICAL PLANS WITHOUT PHARMACY
BENEFITS." 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.
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
and must provide specific citations of the Florida Statutes that establish the
confidentiality or exemption.
All material that is designated as exempt from Chapter 119 must be submitted
in a separate envelope, clearly identified as "PUBLIC RECORDS EXEMPT"
with your name and the Proposal name marked on the outside. If that material is
reauested through a public records reauest, the County will notify the Proposer of
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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.
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 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
15 of 29
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
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
ProposerNendor'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
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established in the State of Florida. The agreement will be submitted to the Monroe
County Board of County Commissioners for final approval.
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SECTION TWO: COUNTY FORMS AND INSURANCE FORMS
[This page intentionally left blank, with forms to follow.]
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RESPONSE FORM
RESPOND TO: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Purchasing Department
GATO BUILDING, ROOM 2 -213
1100 SIMONTON STREET
KEY WEST, FLORIDA 33040
El 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) ❑
❑ I have included a current copy of the following professional and occupational licenses:
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.ore
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.
Total annual premium for Option 1 proposed per Exhibit F: $
Total Projected Incurred Claims for 1/1/2019 through 12/31/2019: $
Proposed Network Discounts: Professional %. Facility %
Performance Guarantees — amount at risk: $
The proposal is an all- inclusive cost. No additional costs or fees will be paid, including but not
limited to travel costs, per diems, telephone charges, facsimile charges, and postage charges.
Mailing Address
Fax:
Signed: Witness:
(Print Name)
(Title)
STATE OF:
COUNTY OF:
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:
Telephone:
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LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 010 -1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
(Company)
"...warrants that he /it has not employed, retained or otherwise had act on his /her behalf
any former County officer or employee in violation of Section 2 of Ordinance No. 010-
1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010-
1990. For breach or violation of this provision the County may, in its discretion,
terminate this Agreement without liability and may also, in its discretion, deduct from the
Agreement or purchase price, or otherwise recover, the full amount of any fee,
commission, percentage, gift, or consideration paid to the former County officer or
employee."
(Signature)
Date:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
personally known to me or has produced
(type of identification) as identification
(name of affiant). He /She is
NOTARY PUBLIC
My Commission Expires:
20 of 29
NON - COLLUSION AFFIDAVIT
I, of the city of
law on my oath, and under penalty of perjury, depose and say that
according to
1. 1 am of the firm
of the bidder
making the Proposal for the project described in the Request for Proposals
for and that I executed
the said proposal with full authority to do so;
2. The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting
competition, as to any matter relating to such prices with any other bidder or
with any competitor;
3. Unless otherwise required by law, the prices which have been quoted in this
bid have not been knowingly disclosed by the bidder and will not knowingly
be disclosed by the bidder prior to bid opening, directly or indirectly, to any
other bidder or to any competitor; and
4. No attempt has been made or will be made by the bidder to induce any
other person, partnership or corporation to submit, or not to submit, a bid for
the purpose of restricting competition;
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.
STATE OF:
COUNTY OF:
(Signature)
Date:
Subscribed and sworn to (or affirmed) before me on
(date) by
known to me or has produced
as identification.
(type of identification)
NOTARY PUBLIC
My Commission Expires:
21 of 29
(name of affiant). He /She is personally
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.
(Signature)
Date:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on (date) by
(name of affiant). He /She is personally known to me or has
produced (type of identification) as identification.
NOTARY PUBLIC
My Commission Expires:
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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)
STATE OF:
Date:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
known to me or has produced
(type of identification) as identification.
of affiant). He /She is personally
NOTARY PUBLIC
My Commission Expires:
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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.
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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.
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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.
26 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
27 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.
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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
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29 of 29
LOCAL PREFERENCE FORM
A. Vendors claiming a local preference according to Sec. 2 -349, Monroe County Code must complete
this form.
Name of Proposer/Responder Date:
1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax
Collector dated at least one year prior to the notice or request for bid or proposal?
(Please furnish copy.)
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:
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:
Tel. Number
Print Name:
30 of 29
Seal
Exhibit A — Scope of Services 11 1
The Proposer will be evaluated 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 an Amendment, Endorsement, or Rider to
the County to accommodate non - standard contract provisions agreed to by the Proposer.
Check the applicable box for each service offered. Only provide explanations if you cannot comply
fully with the requested service.
Yes
No
Yes, Can Comply but with
Service Requirement
Can
Cannot
Specified Deviations
Comply
Comply
(please detail deviations
below
This Agreement shall be governed
by and construed in accordance
with the laws of the State of Florida
applicable to Agreements made and
to be performed entirely in the State.
(Please include a copy of a sample
p olicy in Tab 6 for review
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 services to be provided.
Provide firm pricing for the effective
date of the contract based on the
information provided in the RFP.
Variations in actual enrollment shall
have no effect on the proposal. The
proposal shall be valid regardless of the
final enrollment mix, number of
Awardees, number of plan designs, or
outcome.
The Current TPA has a contractual'
provision to assess a $150,000 early
termination fee. Please indicate
whether you will assume this expense
on the County's,' behalf', if you are
awarded this business.
All charges for any service or optional
service must be clearly outlined in the
Pricing Exhibit.
Exhibit A — Scope of Services 11 1
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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.
Provide a toll free number and sufficient
staffing to handle inquiries directly from
staff and plan members.
Provide an experienced
Implementation Manager/Team
responsible for the accuracy and
timeliness of the implementation.
Provide an Account Manager or
Account Executive responsible for
the overall relationship.
Participate in open enrollment meetings
on an annual basis.
Participate in onsite meetings at
various County locations to review
plan results, as needed.
Make timely and accurate claims
payments to medical providers in
accordance with plan provisions.
Provide billing & eligibility services
to the County
Accept enrollment via paper,
online enrollment, and /or
electronic files.
Provide effective programs to
manage participant health as well
as claim costs.
Provide services, including but not
limited to:
• Coordination of benefits
• Subrogation /recovery
• Fraud investigation
• Utilization Review
Integrate Large Claim
Management, Case Management,
and Disease Management
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No
Yes, Can Comply but with
Service Requirement
Can
Cannot
Specified Deviations
Comply
Comply
(please detail deviations
below)
services to provide seamless and
effective care and cost
management services to the
County and its Participants.
Provide monthly, quarterly and
annually detailed claims reports to
the County and the consultant
electronically.
Provide ad hoc reports, upon
request, at no charge.
Ensure accurate and seamless
integration of medical and Rx
claim accumulator information for
the carved out Prescription Drug
Program.
Provide a 24 hour nurseline for
participants' use.
Provide outreach to members with
targeted conditions or risk factors.
Monitor and manage networks to
ensure sufficient medical provider
and hospital coverage for all
medical services.
Collaborate with the County to
ensure continued network
satisfaction.
Ensure appropriate transition of
care to the County's plan
participants as needed.
Provide Health Risk Assessments
— online or in person — at least at
a minimum once annually.
Provide Biometric Screening for
all plan participants, at least once
annually.
Provide one -on —one health
coaching from qualified medical
personnel.
Provide professional staff to help
drive the development of Wellness
Initiatives.
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No
Yes, Can Comply but with
Service Requirement
Can
Cannot
Specified Deviations
Comply
Comply
(please detail deviations
below)
Design, develop, and direct Health
Fairs for plan participants.
Design, develop and direct
employee wellness activities — at
least quarterly.
Provide outreach to employees
with critical scores on the
HRA/Biometric Screenings.
Provide the results of Biometric
screenings to the Claims
Administrator / Disease
Management vendor.
Design, develop and direct
employee educational activities —
at least quarterly.
Provide estimated renewal rates
120 days in advance of renewal.
Produce and distribute all
appropriate materials, including but
not limited to: enrollment materials,
plan booklets & schedules of
benefits, summary of benefits
SBC's , provider lists, etc.
Provide sufficient time for the
County to review and approve all
open enrollment communication
materials prior to release to
employees.
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No
Yes, Can Comply but with
Service Requirement
Can
Cannot
Specified Deviations
Comply
Comply
(please detail deviations
below)
Provide performance guarantees
with financial penalties for non-
performance. Performance
guarantees should include:
• Maintaining Network
Access
• Maintaining promised
discounts
• Claim turnaround time
• Claim payment accuracy
• Participant satisfaction
No party to this Agreement shall be
required to enter into any
arbitration proceedings related to
the Agreement.
Comply with the Florida Local
Government Prompt Payment Act,
Section 218.70, Florida Statutes.
The Provider 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 this
Agreement with ninety (90) days'
written notice to the County.
The County may terminate this
Agreement with or without cause upon
thirty (30) days' written notice to the
Proposer.
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Exhibit A — Scope of Services II 1
Service Requirement
Yes
Can
Comply
No
Cannot
Comply
Yes, Can Comply but with
Specified Deviations
(please detail deviations
below)
Agree to the following: "Pursuant to
Florida Statute §119.0701, Proposer
and its 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."
The Proposer does hereby consent and
agree to indemnify and hold harmless
the County, its Mayor, the Board of
County Commissioners, appointed
Boards and Commissions, Officers, and
the Employees, and any other agents,
individually and collectively, from all
fines, suits, claims, demands, actions,
costs, obligations, 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
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Exhibit A — Scope of Services II
Service Requirement
Yes
Can
Comply
No
Cannot
Comply
Yes, Can Comply but with
Specified Deviations
(please detail deviations
below)
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 of this contract. The
amount and type of insurance coverage
requirements set forth hereunder shall
in no way be construed as limiting the
scope of indemnity set forth in this
paragraph. Further the Proposer
agrees to defend and pay all legal costs
attendant to acts attributable to the sole
negligent act of the Proposer.
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EXHIBIT B
Questionnaire
Fully- Insured Medical Questionnaire
Submit responses in Hard Copy and Electronic Version in
a useable Microsoft Word format.
For your convenience, Exhibit B is also available as a separate
downloadable document in a useable Microsoft Word format.
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
General Company Information
1. Is your company currently in compliance with the Florida Department of Insurance financial and reserve
requirements? Yes or No. If no, please explain your answer.
2. When did your organization enroll its first group in Florida for each type of coverage listed?
Type of Coverage
Date
PPO products
HMO Products
Consumer- Driven products
Self- Funding
Wellness /Disease Management
3. Provide the enrollment data (including all plans) requested below for the organization submitting this
Proposal:
a.) Florida Enrollment
1/1/2015 1 /1 /2016 1/1/2017
Commercial Enrollment
Medicare Enrollment
Medicaid Enrollment
Other Enrollment
Total Enrollment
b.) South Florida (Miami -Dade and Monroe Cour
1/1/2015
Enrollment
1/1/2016 F1 /1/2017
Commercial Enrollment
Medicare Enrollment
Medicaid Enrollment
Other Enrollment
Total Enrollment
c.) Monroe County Enrollment
1/1/2015 1 /1 /2016 1/1/2017
Commercial Enrollment
Medicare Enrollment
Medicaid Enrollment
Other Enrollment
Total Enrollment
4. What percent of your Florida enrollment in 2016 and 2017 is from public sector clients? What percentage
is fully- Insured vs. self- funded for 2016?
Total 2016 % of 2017 % of 2016% 2017%
Florida Enrollment Enrollment Public Public Fully- Self- Funded
Sector Sector Insured
Enrollment
5. Is your company offering its group medical coverage through a trust, licensed or registered outside the
State of Florida? Yes or No. If yes, please provide the name of the trust and in which state it is licensed
or registered.
6. What is your company's current commitment to continuing to offer group medical benefit plans in the
State of Florida?
7. Does your company have any plans within the next 36 months to stop offering medical benefit coverage
in Monroe County?
8. Provide NCQA, JCAHO, AAA and/or any other accreditation status that applies to the programs you are
proposing. Provide a copy of your accreditation letter(s). Please provide the dates for each certification
and accreditation program you maintain.
9. Detail any mergers /acquisitions involving your organization which have occurred in the last 12 -month
period, and any which are planned for the next 12 to 24 months.
10. Is your company currently or in the past five (5) years been investigated by, asked to appear or give
testimony, examined or audited by a State or Federal regulatory agency? Yes or No. If yes, please
provide information and details of the outcome.
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
General Plan Information
1. Does your company agree to cover all employees, retirees and dependents who are currently covered for
medical benefits by the present carrier who may be actively at work, disabled, on leave of absence, on
military leave or have other extenuating circumstances? Yes or No. If no, please explain your answer.
2. What, if any, benefit limitations or deviations does your company have in relation to the model group
medical benefit plans requested in this RFP? Please provide a listing of all deviations in Tab 6.
3. Address any system limitations or vendor data sharing issues you would face due to:
a. Carving out wellness/disease management programs
b. Maintaining the carved out pharmacy program and the EGWP Program through Envision Rx.
c. Maintaining the County's exemption from the Mental Health Parity and Addition Equity Act (MHPAEA)
4. Describe, in detail, your out -of -area coverage for members, both within and outside the United States who
may either reside out of area or who maybe travelling out of area. Describe your capabilities for
negotiating fees with out -of -area providers and the cost for such services.
5. Does your plan cover members that utilize services offered through a walk -in facility such as those
located in a retail environment? Yes _ No _. If yes, are there any limitations?
6. Does your company offer the following in the State of Florida?
a. True group Medicare Supplement Plan: Yes or No
b. Medicare Advantage Plan: Yes or No
c. Medicare Part D or a Senior Care: Yes or No
d. EGWP Plan integrated with Insured product: Yes or No
If yes, please provide a description of the benefits available with marketing and pricing materials for
the plan.
7. Is your company willing to offer a multi -year rate guarantee on the premiums offered in your RFP
response? Yes or No
a. If yes, please explain the scope of guarantees.
b. If no, please explain why not.
8. Will your company offer a percentage increase ceiling (guarantee) on the first renewal for the premiums
offered in your RFP response? Yes or No. If yes, please provide the scope of the ceiling
9. Will your company guarantee the annual trend on medical on the renewal in future years? Yes or No
If yes, please provide detailed information of the guarantees.
10. Is your contract cancelable for any reason other than non - payment of premium? Yes or No
If yes, please provide reasons for cancellation.
11. Is your company capable of sending and receiving employer information electronically for billing,
enrollment and eligibility? Yes or No
12. For enrollment purposes, will your company accept an Excel Spreadsheet to transfer of the current
eligibility files instead of conducting a hard copy enrollment? Yes or No. Please list any mandatory
specifications in layman's terms. If no, how do you propose to do enrollment?
13. Can Monroe County enter eligibility directly into your system through an administrative portal? Does this
information update in real time? If not, how long does it take for eligibility information to become active in
the eligibility and claim system?
14. Please explain how your company audits monthly eligibility and reconciles each month's billing?
15. Are eligibility and claims administered on the same system? Yes or No. If no, how are these functions
integrated?
16. Will the County have a dedicated team for claims and customer service? Yes or No
17. Do you plan on major changes or upgrades to your administrative system or the platform you are proposing
for the County in the next 24 months? Yes or No. If yes, please explain.
18. Will you provide the County with an eligibility contact person for eligibility file issues and questions? Yes
or No.
19. What eligibility responsibilities does your organization expect the County to perform?
20. Will your company guarantee that they are HIPAA compliant? Yes or No.
21. Since the implementation of HIPAA, has your company been questioned, interviewed, audited or received
a violation notice concerning HIPAA compliance? Yes or No. If yes, please provide details.
22. Monroe County BOCC has a large population of retirees, over and under the age of 65, who participate in
the group medical plan. Will your company provide medical coverage for the retiree population who now
participate in the group medical plan? Yes or No. If no, what alternatives are you offering for this group?
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Medical Benefits Information
Monroe County is proposing the option of five (5) types of medical benefit plans to its employees. The (5)
types of medical plans that will be offered are HMO, POS/PPO an HDHP and one Medicare Retiree
medical plan that accommodate EGWP plans. Can your company:
a. Provide each of the alternatives? Yes or No
b. Provide any of the plans on a standalone basis or in any combination? Yes or No.
c. Administer an HSA for the HDHP? Yes or No.
If your company answered no to any of the above, please explain.
2. Monroe County will need enrollment assistance each year for the annual open enrollment. Please confirm
the type of enrollment assistance your company will be providing for the annual open enrollment?
3. What are your company's projected and past medical trends for the following years?
4. Please provide information on your company's coordination of benefits procedures. How do you
coordinate with other carriers?
5. Assuming that the employee's coverage is the first listed, does your company co- ordinate benefits
between:
a. HMO and an HMO?
PPO
HMO
HDHP
Indemni
2018
d. POS and a PPO?
Yes or No.
e. PPO and a PPO?
Yes or No.
2017
2016
2015
4. Please provide information on your company's coordination of benefits procedures. How do you
coordinate with other carriers?
5. Assuming that the employee's coverage is the first listed, does your company co- ordinate benefits
between:
a. HMO and an HMO?
Yes or No.
b. HMO and a POS?
Yes or No.
c. HMO and a PPO?
Yes or No.
d. POS and a PPO?
Yes or No.
e. PPO and a PPO?
Yes or No.
6. What is the average amount or percentage of savings attributable to this effort?
Does your company subrogate claims? Yes or No. If yes, please provide the amount or percentage of
cost saving to the plan attributable to this effort.
Is there a charge back to the County for Subrogation Services? Yes or No? If yes, how is the client
charged? If yes, also please provide the amount or percentage of cost saving to the plan attributable to
this effort.
9. What Diabetic supplies (i.e. insulin pumps) are payable under the Medical portion of the plan?
10. Are Self Injectable drugs payable under the Medical portion of the plan? Yes or No.
11. Please provide your company's contract definition of durable medical equipment.
12. Please advise if the following reviews /certifications are required under your Medical plans as proposed.
a. Preadmission certification? Yes or No.
b. Second surgical opinion? Yes or No.
c. Concurrent review? Yes or No.
d. Large case management? Yes or No.
Please provide the percentage of cost savings attributed to each area.
13. Who is responsible for ensuring that the required reviews /certifications are performed when members use
a network provider? Is the patient held financially harmless if this is not followed? Yes or No.
14. Please provide a copy of your company's renewal formula that will be used to rate the renewal for Monroe
County's account.
15. Please provide your estimated total claims expense for each proposed plan for the 1/1/19 policy year
16. Is your company willing to negotiate the renewal pricing for Monroe County? Yes or No.
17. Will you still provide Medical Insurance to Monroe County with the Pharmacy benefit carved out? Yes or
No.
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Medical Management
Monroe County is a strong proponent of aggressive Medical Management programs that will have a
positive impact on the care of their participants and on the claims experience of their medical plan. Does
your RFP proposal response include a comprehensive Medical Management program that identifies
specific disease states of participating members? Please outline your Medical Management programs,
including such components as Disease Management, Case Management, Discharge Planning,
Continuation of Care, etc.
2. Is your Medical Management program able to integrate with the outside PBM vendor? If so, is there an
additional charge for this service? If so, please outline this cost in the pricing exhibit.
3. Is your Medical Management program included in the proposed rates or will there be an additional charge
for the program? Yes or No. If not included in your proposal, please provide information on the additional
cost to provide a Medical Management program. Please outline this cost in the pricing exhibit.
4. Can you provide an option for the County to make participation in your Medical Management Programs
mandatory for plan participants? Yes or No. If yes, is there an additional cost for this option? Please
provide specifics of any additional cost. Please outline this cost in the pricing exhibit. If no, why do you
not provide this option?
5. How do you ensure the integration of the various components of your Medical Management programs?
Do you provide multiple specialists for members with comorbidities or do you provide a single point of
contact who manages the person. How do you manage "Handoffs" between one clinical area and
another?
6. Does your company provide the services for the Medical Management program or is it subcontracted to
an outside vendor?
a.) Indicate: Company provided or Sub - contracted
b.) If sub - contracted, please provide:
L The name and address of the sub - contracted company
ii. Number of years your company has worked with the sub - contracted company
iii. Number of clients currently using this subcontracted vendor
iv. Date of contract, beginning and expiration
7. If you subcontract your Medical Management, how does your subcontractor access patient benefits,
eligibility, etc.?
8. Please outline the disease states your program targets, identifies and manages. Please provide a listing
of the target diseases /conditions.
9. What criteria does your company use to select targeted diseases /conditions?
10. Does the client have the opportunity to customize the Medical Management program to the specific
conditions prevalent to their membership? Yes or No. If yes, please provide details.
11. Do you have Case Managers who actively assist patients in managing their continuation of care needs as
they progress in the care continuum i.e. from hospital, to SNF or to home? Please describe how plan
participants are assisted and how the outreach is conducted to the member.
12. How does your company promote the member participation in the Medical Management program? When
and how do you begin to offer assistance — at the time of diagnosis or during an active course of
treatment?
13. Please describe your company's approach in encouraging members' participation in the program. Does
your company offer incentives for members to participate in the disease management program? Yes or
No. If yes, please provide details.
14. Briefly describe the member's interaction with your company's Medical Management program. (i.e
brochures, call centers, outreach calls).
15. Does your Medical Management program integrate with the member's medical providers? (PCPs,
specialists, hospitals)? Please provide details.
16. Does your company address appropriateness of care with the medical providers? Yes or No. If yes, how
does your company engage the medical providers?
17. Does your company guarantee security measures to prevent employee health information from access to
the employer? Yes or No. If yes, please provide information on you company's security measures. If no,
please explain how you maintain HIPAA privacy for plan participants.
18. Please explain how your company monitors and measures the performance of your Medical Management
program.
19. Will your company guarantee your RO1 forecast? Yes or No. If yes, what type of guarantees could we
expect?
20. Does your company develop predictive modeling from the information obtained from the Medical
Management program? Yes or No. If yes, please describe how the predictive modeling is used at the
client level.
21. Does your company share the predictive modeling with the client? Yes or No. If yes, please describe
what type of information is shared with the client. How often is this information reviewed? How is it
communicated?
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Wellness
The County is requesting that the Wellness programs be fully lintegrated into your pricing proposal.
Please respond to the questions below specifically with regard to the initiatives included in your
quoted premiums. If you offer additional services, please clearly indicate that they are supplemental
services and indicate the cost for each of these services in the pricing exhibit.
1. Is your wellness plan included in the proposed rates or will there bean additional charge for the program?
If not included in your proposed rates, please provide the additional cost.
Does your company provide the services for your wellness program or is it a sub - contracted plan.
Indicate Owned or Subcontracted.
If sub - contracted, please provide:
The name and address of the sub - contracted company
How many years your company has worked with the sub - contracted company
How many clients your company currently has contracted with this vendor
Date of contract, beginning and expiration
2. Does your wellness program integrate and interact with your company's medical claim system? Yes or
No.
3. Does your company guarantee security measures to prevent employee health information from access by
the employer? Yes or No. If yes, please provide information on you company's security measures. If no,
please explain how you remain in compliance with current regulations.
4. Please describe any evidence you have that demonstrates how your wellness program stands out among
the competition. Does the client's active participation in your Wellness program impact rate increases?
5. Complete the chart below for each service your organization will be providing to Monroe County (check
all that apply). Provide samples of your resources:
10
DELIVERY MODE
OUTSOURCED
VENDOR
Direct
Seminars/One-
Wellness Services
Mail
Online
Telephonic
Onsite
on -One
Name of Vendor
Counseling
Health Risk
Assessment
Biometric Screenings
Diabetic Counseling
Health Coaching
10
6. Describe the support that you provide in the development of a client's wellness program. Please include
specifics regarding the strategic resources that are available to the client.
Is a wellness consultant assigned to the client to assist with the development and management of the
wellness program? What are the qualifications of the wellness consultant? How is time allocated to the
client?
8. Describe your capabilities to manage rewards and incentives. Provide examples of incentives and a
recommended budget for incentives for a client of this size.
9. The County currently receives contributions from the vendor to support wellness activities and to drive
participation into wellness programs. Describe your strategy to drive participation and maintain
participant engagement, and outline the funds that you will provide to the County to support the
wellness program. Please also include this information in the pricing exhibit.
10. Indicate participation and completion rates (pre and post) for clients you have provided the following types
of onsite and online initiatives.
Onsite Initiatives
Participation Rates
Completion Rates
DELIVERY MODE
OUTSOURCED
Weight Loss Challenges Total Weight Loss
Nutrition Programs
(ENDOR
Direct
SeminarslOne-
Wellness Services
Mail
Online
Telephonic
Onsite
on -One
Name of Vendor
Counseling
Health Education &
Awareness
Campaigns
Lunch and Learns
Self Directed
Programs
Resource Facilitator
Health Partnerships
Follow Up Reports
Other (add rows as
needed)
6. Describe the support that you provide in the development of a client's wellness program. Please include
specifics regarding the strategic resources that are available to the client.
Is a wellness consultant assigned to the client to assist with the development and management of the
wellness program? What are the qualifications of the wellness consultant? How is time allocated to the
client?
8. Describe your capabilities to manage rewards and incentives. Provide examples of incentives and a
recommended budget for incentives for a client of this size.
9. The County currently receives contributions from the vendor to support wellness activities and to drive
participation into wellness programs. Describe your strategy to drive participation and maintain
participant engagement, and outline the funds that you will provide to the County to support the
wellness program. Please also include this information in the pricing exhibit.
10. Indicate participation and completion rates (pre and post) for clients you have provided the following types
of onsite and online initiatives.
Onsite Initiatives
Participation Rates
Completion Rates
Walking Programs
Exercise Programs
Weight Loss Challenges Total Weight Loss
Nutrition Programs
Gym /Fitness Center
Participation/Encouragement
11
11. Complete the chart below and provide documentation and evidence for the Lifestyle Management
Programs you will provide to the County (check all that apply). Provide evidence for gender specific
education and awareness (i.e., breast care for women, cardiovascular disease for women, prostate for
men).
12. Indicate your capabilities to manage or offer the following (check all that apply):
Lifestyle
Management
Programs —
Delivery Mode
OUTSOURCED VENDOR
Mailings
Self
Directed
Programs
Telephonic
Coaching
Onsite Seminars
Lunch and
Learns
One -on-
One
Counseling
Other
Heart Disease
Include
Manage
Coordinate
partnership
Name of Vendor
Not
Diabetes &
Diabetic
Counseling
Offered
Cholesterol
Hypertension
Asthma
Nutrition
Fitness & Exercise
Women's Health
Men's Health
Self Care
Smoking
Cessation
Weight
Management
Stress
Management
Other: (identify)
12. Indicate your capabilities to manage or offer the following (check all that apply):
12
SERVICES
'
OUTSOURCED VENDOR
Community
Service
Include
Manage
Coordinate
partnership
Name of Vendor
Not
Offered
Onsite Clinic
Lunch and Learns
Fitness Center
Discounts
Weight Loss
Competitions
Stress Management
(Yoga, Tai Chi, etc.)
12
13. Indicate the type of reporting you use to track, analyze and assess cost savings (check all that apply)
REPORTS
SERVICES
Enrollment
OUTSOURCED VENDOR
Participation
Utilization (Gyms)
Community
Health Risk Change (Pre & Post)
Service
Include
Manage
Coordinate
partnership
Name of Vendor
Not
Claims Savings
❑
Medical
❑
RX ❑ Diagnosis
Offered
Walking Programs
Absenteeism
Productivity
Other: (identify)
Quality of Life
ROI
13. Indicate the type of reporting you use to track, analyze and assess cost savings (check all that apply)
13
REPORTS
FREQUENCY
Monthly, Quarterly or Annuall
Enrollment
Participation
Utilization (Gyms)
Health Risk Change (Pre & Post)
Clinical Outcomes
Participant Satisfaction
Claims Savings
❑
Medical
❑
RX ❑ Diagnosis
Short -Term Disability
Absenteeism
Productivity
Quality of Life
ROI
Administration
Wellness Savings
Wellness Impact
13
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Claim Service
1. Please provide the location of the claim office where Monroe County's claims will be processed.
2. Does your company own and operate the claim facility or is the service sub - contracted to another vendor?
If it is subcontracted, please provide the information about the subcontractor.
3. Please address your claims system's ability to accumulate total out of pocket by member with the
contracted PBM, Envision Rx.
4. Do you currently share accumulator data with this vendor? Yes or No. If no, are you willing to absorb all
programming costs to set up the data exchange on both the medical and pharmacy?
5. What are your claim payment goals and results for 2016 and 2017? Please address turnaround time and
claim payment accuracy.
6. What percentage of services was denied for medical necessity in 2016 and 2017? Of those denials, what
percentage was appealed and subsequently approved? Describe what types (top 5) of services are most
frequently denied and why these services are denied.
PPO
2016
2017
% Denied
% Denied
% Appealed
% Appealed
Subsequently Approved
Subsequently Approved
HMO
2016
2017
% Denied
% Appealed
Subsequently Approved
7. Does your company have auto adjudication capabilities at this location? Yes or No.
a. If yes, what percentages of claims are auto adjudicated? What is the turnaround time?
b. If no, are there plans to implement auto adjudication and when?
8. How many client companies does this claim facility service at this location?
9. How many client members are assigned to this location?
10. What is the ratio of claims processors to members?
11. Does your claim facility have specific claim processors that handle claims for:
14
COB claims:
Yes or No.
Medicare claims
Yes or No.
Subrogation claims
Yes or No.
COBRA claims
Yes or No.
Catastrophic claims
Yes or No.
12. Is your claims operation in compliance with the LANN requirements of Section 1557? What language
interpretation services (languages) do you provide?
13. Does your claim facility have "toll free" telephone numbers available for the employer and member
access? Yes or No.
14. Does your company offer claim viewing and/or claim submission via the internet or website? Yes or No.
What restrictions are placed on the Group Plan Administration with regard to viewing claims information?
15. What are the days and hours of operation for this claim facility?
16. The claim facility is closed in observance of what specific holidays?
17. Does your company have any plans to change the location of the claim operation with -in the next 36
months? Yes or No. If yes, please provide the details.
18. Does your company have plans to down size or reduce the number of employees at the claim facility with-
in the next 36 months? Yes or No. If yes, please provide the details.
19. Does your company have plans to upgrade, enhance or change the software or computer system used to
process claims within the next 36 months? Yes or No. If yes, please provide the details
20. Does your company verify overage dependent eligibility? Yes or No.
21. How does your company handle overage dependents that are permanently disabled and remain on the
medical plan?
a. How often does your company verify these dependents?
b. What procedures does your company use to verify these dependents?
15
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Member Service
1. Where is the location of your member service unit that will be servicing the members of Monroe County?
2. Is this a central or regional servicing office?
3. Does your company own and maintain the member service unit? Yes or No. If no, please explain
4. What are the days and hours of operation for your member service unit?
5. Are there member service representatives available 24/7? Yes or No.
6. The Member Service operation is closed in observance of what specific holidays?
7. Does your company use home based member service representatives that report to this location? Yes or
No. If yes, how long has your company been utilizing home based member service representatives and
what percentage of member service calls are handled by home based employees.
8. Does your company use off shore based member service representatives at this location? Yes or No. If
yes, how long has your company been utilizing off shore member service representatives and what
percentages of member service calls are handled off shore?
9. Does your company have any plans with in the next 36 months to move or relocate the member service
unit? Yes or No. If yes, please provide details.
10. Does your company plan within the next 36 months on downsizing the staff of the member service unit?
Yes or No. If yes, please provide details.
11. Does your company plan within the next 36 months to up grade or change the computer system your
member service unit is currently using? Yes or No. If yes, please provide details
12. Does your company's member service unit have a "toll free" telephone number for employer and member
access?
13. What are your organization's target goals for the following metrics?
Average Speed of Answer
Average Length of Call
First Call Resolution Rate
Call Abandonment Rate
16
14. Does your company supply a medical I.D. Card to each member with the appropriate benefits listed,
member service and claim office "800" numbers? Yes or No.
15. Can members order and/or download new I. D. cards on -line via your company's web site? Yes or No. If
no, please give details as to how a member can request a new I.D. card.
16. Can HMO members change their PCP on -line via the web site? Yes or No. If yes, please provide details.
If no, please provide details as to how a member changes PCPs with your company.
17
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Financial Reporting
Medical /RX Claim Reports
1. Will your company provide financial and medical claim reporting at no charge to the County for each of
the group medical plans you have responded to in this RFP? Yes or No.
At a minimum, The County will require the following reports on a monthly, quarterly, annual or ad hoc
basis. Will your company supply the following reports?
Monthly
Total insurance premium /claims by month, paid and incurred, by plan with YTD: Yes or No.
Loss ratio statistics: Yes or No.
Lag Reports: Yes or No
Claims broken out by employees and dependents: Yes or No.
Claims broken out by plan of benefits: Yes or No.
Claims broken out by actives and retirees under age 65 and over age: 65. Yes or No.
Claims broken out by employees of the BOCC and each Constitutional Office: Yes or No.
Number and types of encounters: Yes or No.
Encounters by providers: Yes or No.
Quarterly
Demographic summary for medical: Yes or No.
Key Statistics, Claims for office visits, specialist
admissions, days per 1,000, ALS, etc.: Yes or No.
Catastrophic claims: Yes or No.
Network discount analysis (billed versus paid analysis)
Trend analysis: Yes or No.
Inpatient analysis: Yes or No.
Ambulatory analysis: Yes or No.
visits, inpatient, ambulatory, E.R. visits,
Yes or No.
Hospital utilization (top 25 hospitals) and profile: Yes or No.
Top 25 diseases by claim amount: Yes or No.
Disease management statistics: Yes or No.
Wellness statistics: Yes or No.
Ad Hoc
Detailed year to date roll up claim report Yes or No.
Comprehensive year end claim report: Yes or No.
Claims Detail by specific type of Provider or type of utilization: Yes or No.
Please provide samples of the financial and claim reports available from your company. Please clearly
indicate which reports are standard and which are optional for an extra charge. Place the samples in Tab
6.
4. Does your company provide access to claim experience information on -line? Yes or No. Is this
information real time if not, when are monthly reports available?
18
5. Is your company willing to provide a representative to attend meetings with Monroe County Administrators
and Commissioners to conduct detailed discussions concerning the financial medical claim reports? Yes
or No. If yes, how often?
19
Monroe County Board of County Commissioners
Fully Insured Medical Questionnaire
Provider Networks
Please respond to each Provider Network question for all networks you are proposing.
1. What types of medical provider networks does your company offer in Monroe County Florida?
a. HMO
Yes or No
b. POS
Yes or No
c. EPO
Yes or No
d. PPO
Yes or No
2. Does your company own or lease the medical network?
If your company leases the network, please provide information concerning the network company
3. Have you changed the size or structure of either the primary care or specialty care network for Monroe or
Miami -Dade Counties during the past 12 months? Yes or No. If yes, explain.
4. Complete the following GeoAccess summary for the County's employees. Your study must include a
summary report for each of the items listed below. Each summary must indicate the total number and
percentage of employees with access by zip code and by city for all networks that you are proposing.
Please include GeoAccess Reports with your proposal in Tab 6.
All Geo Access are to be based on driving distance
• Number and percentage of employees with two adult Primary Care Physicians (Family Practice,
General Practice, Internists) within ten miles of the employee's zip code.
• Number and percentage of employees with two Pediatricians within ten miles of the employee's
zip code.
• Number and percentage of employees with two OBIGYNs within ten miles of the employee's zip
code.
• Number and percentage of employees with two Specialists within twelve miles of the employee's
zip code.
• Number and percentage of employees with one hospital within twenty miles of the employee's zip
code
Driving
'Distance
PPO /POS>
Adult PCP's
2 in 10 miles
Pediatricians
2 in 10 miles
OBIGYN
2 in 10 miles
Specialists
2 i 12 miles
Hospitals
1 in 20 miles
Number meeting standard
% meeting standard
20
Driving
'Distance
HMO
Adult PCP's
2 in 10 miles
Pediatricians
2 in 10 miles
OBIGYN
2 in 10 miles
Specialists
2 i 12 miles
Hospitals
1 in 20 miles
Number meeting standard
OBIGYN
2 in 10 miles
Specialists »
2 in 12 miles
Hospitals
1 in 20 miles
EXAMPLE
% meeting standard
Marathon - 5
5. Complete the following GeoAccess summary for the County's participants using the same access standards
as above. Please list the number of participants in the top 5 CITIES that do not meet the access
standards.
6. Provide an electronic list (on a diskette or CD, in only usable Excel format) of your most up -to -date provider
directory for Monroe and Miami -Dade Counties ONLY. Please provide individual participating providers
by name even if they have the same TIN or NPID. The required format for the list follows:
Last Name, First Name, Middle Initial, Address, Address 2, City, State, Zip, NPID, Specialty, Network
designation.
FORMATTING: Each item must be separated into separate cells and all numbers must be formatted as
numbers. Provide this information for all of the networks that you are proposing. If you are using different
networks, provide all networks proposed and identify each network. Please note that if the information is
not provided in the exact format requested, your rating in this area will be compromised.
7. Have there been any changes to your South Florida (Monroe and Miami -Dade) hospital network in 2017?
Yes or No. If yes, please explain the changes.
8. List what steps your organization will take to ensure that the proposed hospital network remains stable
specifically within the Monroe County area.
9. Are there any hospitals in the South Florida (Monroe and Miami -Dade) area with which you are not
contracted? Yes or No. If yes, list all hospitals.
10. Indicate your contract status for each of your participating hospitals as well as your top ten physician -
physician group providers (by number of encounters) in Monroe County Only Indicate the current contract
status and the contract's expiration date. If these differ by networks proposed, please complete for each
network proposed.
21
Driving
Distance
List City and
number without
access
Adult PCP's
2 in 10 miles
Pediatricians
2 in 10 miles
OBIGYN
2 in 10 miles
Specialists »
2 in 12 miles
Hospitals
1 in 20 miles
EXAMPLE
Marathon - 5
Key West - 3
Key Largo -1
Key West -1
None
6. Provide an electronic list (on a diskette or CD, in only usable Excel format) of your most up -to -date provider
directory for Monroe and Miami -Dade Counties ONLY. Please provide individual participating providers
by name even if they have the same TIN or NPID. The required format for the list follows:
Last Name, First Name, Middle Initial, Address, Address 2, City, State, Zip, NPID, Specialty, Network
designation.
FORMATTING: Each item must be separated into separate cells and all numbers must be formatted as
numbers. Provide this information for all of the networks that you are proposing. If you are using different
networks, provide all networks proposed and identify each network. Please note that if the information is
not provided in the exact format requested, your rating in this area will be compromised.
7. Have there been any changes to your South Florida (Monroe and Miami -Dade) hospital network in 2017?
Yes or No. If yes, please explain the changes.
8. List what steps your organization will take to ensure that the proposed hospital network remains stable
specifically within the Monroe County area.
9. Are there any hospitals in the South Florida (Monroe and Miami -Dade) area with which you are not
contracted? Yes or No. If yes, list all hospitals.
10. Indicate your contract status for each of your participating hospitals as well as your top ten physician -
physician group providers (by number of encounters) in Monroe County Only Indicate the current contract
status and the contract's expiration date. If these differ by networks proposed, please complete for each
network proposed.
21
PPO — MONROE COUNTY
HMO — MONROE COUNTY
11. Complete the following table for your proposed Networks for Monroe County off. Use your current provider
panel. (Use actual number of individual providers, not offices).
Provider Type
PPO
Monroe County
HMO
Monroe Count
Allergy & Asthma
Cardiologists
Cardiovascular Surgeons
Chiropractors
Dermatologists
22
Endocrinologists
Number of
Number of
ENT
Percentage of
Percentage of
Gastroenterologists
PCPs
Specialty
General Surgeons
Specialty
Physicians
Geriatricians
Lab
Physicians
Hematologists
Physicians
Board Certified
HIV /AIDS Physicians that specialize in HIV /AIDS
treatment
Offering
Offering
Infectious Disease
Accepting New
or Board - eligible
Neurologists
Care
Facilities
Neurosurgeons
Patients
Non -013 Gynecologists
Obstetrician/Gynecologists
Care
Oncologists
Care
Ophthalmologists
Orthopedic Surgeons
Health Care '>
Pediatricians
Agencies
Podiatrists
Primary Care Physician
Pulmonolo ists
Miami -Dade
Rheumatolo ists
Urologist
12. Complete the following exhibit for Monroe and Miami -Dade Counties for your PPO networks.
County
Number of
Number of
Percentage of
Percentage of
Percentage of
Number
PCPs
Specialty
PCPs Accepting
Specialty
Physicians
Hospitals
Lab
Physicians
New Patients
Physicians
Board Certified
Care
Offering
Offering
Facilities >
Accepting New
or Board - eligible
Care
Facilities
Tertiary
Patients
Monroe
Hospitals
Care
Miami -Dade
Care
13. Complete the following exhibit for Monroe and Miami -Dade Counties for your HMO networks.
23
Number
Number
Number of
Number of
Number of
Number
Number of
County
of
of Urgent
Hospitals
Hospitals
Lab
of
Pharmacies
Acute
Care
Offering
Offering
Facilities >
Home
Care
Facilities
Tertiary
Inpatient
Health
Hospitals
Care
Behavioral
Care
Health Care '>
Agencies
Monroe
Miami -Dade
13. Complete the following exhibit for Monroe and Miami -Dade Counties for your HMO networks.
23
County
Number of
Number of
Percentage of
Percentage of
Percentage of
Number
PCPs
Specialty
PCPs Accepting
Specialty
Physicians
Hospitals
Lab
Physicians
New Patients >
Physicians
Board Certified>
Care
Offering
Offering
Facilities
Accepting New
or Board - eligible
Care
Facilities
Tertiary
Patients
Monroe
Hospitals
Care
Miami -Dade
Care
14. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and radiology) affiliated with
network hospitals contracted? For the PPO? Yes or No. For the HMO? Yes or No. If no, list any hospital
physician group(s) not contracted. Please include the hospital affiliation.
15. If covered services are not available within the contracted network, how do members obtain necessary
service? Does this differ between the PPO and HMO products?
16. What fee schedule do you use for out -of- network benefits on the PPO /POS plan? Can you administer
alternate fee schedules upon the County's request? Yes or No.
17. Are PCP and Specialist contracts evergreen? Yes or No. What are the termination requirements within your
provider contracts as far as timeframes and notification? If this differs between the PPO and HMO please
respond for both.
18. How and when do you notify clients and members of pending network terminations? If this differs between
the PPO and HMO please respond for both.
19. What provisions are made for transition of care if a provider is terminated by your plan? What provisions are
made if the provider terminates the contract? Will ongoing services be treated as in- network? If this differs
between the PPO and HMO please respond for both.
20. Provide the number of contracted ancillary facilities /locations by plan type for Monroe County only.
Ambulatory Surgery Centers
Bone Density Testing
Convenient Care Clinics /Retail Clinics
DME Providers
Home Health Care Agencies
24
Number
Number
Number of
Number of
Number of
Number
Number of
County
of
of Urgent
Hospitals
Hospitals
Lab
of
Pharmacies
Acute
Care
Offering
Offering
Facilities
Home
Care
Facilities
Tertiary
Inpatient
Health
Hospitals
Care
Behavioral
Care
Health Care
1 1
Agencies
Monroe
Miami -Dade
14. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and radiology) affiliated with
network hospitals contracted? For the PPO? Yes or No. For the HMO? Yes or No. If no, list any hospital
physician group(s) not contracted. Please include the hospital affiliation.
15. If covered services are not available within the contracted network, how do members obtain necessary
service? Does this differ between the PPO and HMO products?
16. What fee schedule do you use for out -of- network benefits on the PPO /POS plan? Can you administer
alternate fee schedules upon the County's request? Yes or No.
17. Are PCP and Specialist contracts evergreen? Yes or No. What are the termination requirements within your
provider contracts as far as timeframes and notification? If this differs between the PPO and HMO please
respond for both.
18. How and when do you notify clients and members of pending network terminations? If this differs between
the PPO and HMO please respond for both.
19. What provisions are made for transition of care if a provider is terminated by your plan? What provisions are
made if the provider terminates the contract? Will ongoing services be treated as in- network? If this differs
between the PPO and HMO please respond for both.
20. Provide the number of contracted ancillary facilities /locations by plan type for Monroe County only.
Ambulatory Surgery Centers
Bone Density Testing
Convenient Care Clinics /Retail Clinics
DME Providers
Home Health Care Agencies
24
Hospice Agencies
Hospice Facilities
Mammogram Facilities
Occupational Therapists
Outpatient Laboratories
Physical Therapists
Radiology Centers
Rehabilitation Facilities (Inpatient)
Skilled Nursing Facilities
Speech Therapists
Urgent Care Facilities
21. What types of Accountable Care Organization (ACO) or similar programs /models do you have in place
already and what do you have planned for 2018 and 2019? Will any of these programs be available to
Monroe County's participants? If this differs between the PPO and HMO products please provide details
for both.
22. Are there any costs /charges over and above the premium to the County in order for employees to receive
care from an ACO or similar program /model? If yes, what are the costs and how will it work? If this
differs between the PPO and HMO products please provide details for both
23. Who funds the incentive for the providers that participate in an ACO or similar program /model and how do
they fund it? If this differs between the PPO and HMO products please provide details for both
24. How will members determine which providers are participants of the ACO or similar program /model? If
this differs between the PPO and HMO products please provide details for both
25. Does your company offer medical provider information on line? Yes or No. If no, how is network
information made available?
If yes, can the provider information be accessed by:
Total network of physicians and hospitals? Yes or No.
Search by physician's name? Yes or No.
Search by physician's specialty? Yes or No
Search by physician's zip code? Yes or No.
Hospitals by county? Yes or No.
Hospitals by zip code? Yes or No.
Hospitals by physicians admitting privileges? Yes or No.
Can the network information be downloaded and printed? Yes or No.
25
14. Do members have to live in a networked zip code to be considered in- network? Yes or No.
15. How does your company handle out of state eligible dependents when the employee has selected an
HMO plan for their coverage?
16. Is your company offering an open access option plan HMO and/or POS (non referral)?
a.HMO: Yes or No.
b. POS: Yes or No.
17. Does your company require the members to select a primary PCP for the HMO and/or POS products?
Yes or No.
18. What are the procedures for a member to change a PCP? Can change be made on line?
19. How often can a member change their PCP? When is the new PCP provider effective?
20. Can female members select either a PCP or an OBGYN as their PCP?
Yes or No. If no, how are OBGYN visits handled in your plan?
21. Are HMO /POS members required to obtain referrals for every specialist visit?
Yes or No. If yes, please explain.
22. Can HMO /POS members access a specialist referral without a PCP visit? Yes or No.
23. Do any of your PCP's not have admitting privileges to your South Florida network hospitals? Yes or No
If yes, how many?
24. Does your company offer Urgent Care coverage? Yes or No.
25. Can members choose Urgent Care practices as their PCP in the HMO? Yes or No.
26. Do your contracts for PCP's and specialists contain any type of withhold or bonus arrangement? Yes or
No. If yes, please explain.
27. Do your PCP and specialists contracts contain provisions for the employer and members to be held
harmless from any fees for service that are plan eligible, but not paid by the plan regardless of the
reason? (excludes co- payments, deductibles and coinsurance)
28. Do your PCP and specialist contracts contain wording to restrict the provider from balance billing for in
network services? Yes or No. If no, how do you protect members using network providers from balance
billing?
29. Do you subcontract for Behavioral Health and Substance Abuse services? Yes or No. If yes, please
provide the details of your subcontractor.
30. Can the County's EAP directly refer a member to a Behavioral Health care provider? Yes or No. If no,
describe the process for the EAP to obtain authorization for services.
26
31. How would transition of care be handled for members currently under care with a provider that is not in
your existing network, including timeframes? How would transition of care be handled if a provider is
terminated during the course of treatment?
32. List the Behavioral Health facilities under active contract in South Florida (Monroe and Miami -Dade
Counties).
Specialty
Facility Name
Location
Mental Health Facilities
2016
2017
Inpatient
2017
Average allowed cost per
admission
Intensive Outpatient
Substance Abuse Facilities
Average allowed cost per
da
Inpatient
Intensive Outpatient
Residential Treatment Facilities
Average length of sta
33. What percentage of your contract physicians are board certified in Psychiatry? %
34. What is your overall network pricing as compared to prevailing Medicare reimbursement for hospitals and
for physicians? Please answer separately for Monroe and Miami -Dade Counties.
35. Do any network contracts include outlier provisions? Yes or No. If yes, explain.
36. Are changes to your network pricing planned for 2017 or 2018? If so, describe.
37. Do your provider contracts include language to address "Never Events ", including non - payment and hold
harmless for such events? Are patients held harmless in these cases?
38. Provide hospital cost data for Monroe County Only
39. For out of network benefits in your POS and PPO plans, does your company use reasonable and
customary or MAC (provider contracted rate) pricing for claim adjudication?
40. Are all of your contracted providers required to carry medical malpractice insurance? If any providers are
not required to carry medical malpractice insurance, list all types of providers that are not required to
maintain medical malpractice insurance.
27
PPOIPOS
HMO
2016
2017
2016
2017
Average allowed cost per
admission
Average allowed cost per
da
Average discount level
Average length of sta
Days per 1000
Admissions per 1000
39. For out of network benefits in your POS and PPO plans, does your company use reasonable and
customary or MAC (provider contracted rate) pricing for claim adjudication?
40. Are all of your contracted providers required to carry medical malpractice insurance? If any providers are
not required to carry medical malpractice insurance, list all types of providers that are not required to
maintain medical malpractice insurance.
27
41. If contracted providers are not required to maintain medical malpractice insurance, why? What
percentage of your network providers carry no malpractice insurance?
42. Proposer must complete the CPT list (Exhibit E) in full for both the HMO and PPO /POS. The rates should
be based on average reimbursements for Monroe County and Miami -Dade County providers separately,
NOT on statewide or MSA provider averages. Use reimbursement rates as of January 1, 2018.
43. Have you changed affiliations for ancillary services (diagnostic services, prescription drug benefits, etc.) in
Monroe or Miami -Dade Counties during the past 12 months? Yes or No. If yes, describe such changes.
44. Indicate if you have a "Centers of Excellence" program for each of the following and list your designated
facilities for each:
Yes or No Facility(ies) Name(s): In Network or Out of Network
Transplants
Cardiovascular
Cancer
HIV/AIDS
Neonatal
Other
45. Describe your organization's policies regarding your "Centers of Excellence" program. Indicate if the
program is voluntary or mandatory.
46. When members access a Center of Excellence, are they considered to be in network and will receive the
appropriate network benefits? Yes or No. If no, please explain.
47. Will your organization provide information directly to the plan participant to make provider selections that
provide the best outcomes and best costs? If so, please explain.
48. What quality and cost data do you make available to members for selecting hospitals, clinics, imaging
centers, labs and physicians in your network for provider comparison? What additional data will be
available in 2018 and 2019?
49. What quality, cost, satisfaction, and outcome data is available for the plan sponsor regarding in network
providers (specifically cancer care, orthopedics, maternity, heart disease, behavioral health, pediatrics,
emergency care, etc.)? How is this data provided to plan sponsors?
50. Is your provider credentialing process conducted in -house or delegated to another organization? If
delegated, provide name of the organization and how long the functions have been delegated.
51. Do credentialing policies and procedures meet accreditation standards? Yes or No. If yes, what
accreditation organization?
52. How long does it take to credential a new physician? How often does your Credentialing Committee
meet?
28
53. How often do you re- credential network providers?
54. Between re- credentialing cycles, do you conduct ongoing monitoring of practitioner sanctions, complaints
and quality issues? Yes or No. If yes, how often?
55. Does your company provide a grievance procedure specifically for members who have problems with
certain providers? Yes or No. If yes, please provide what types of complaints are heard and what the
process is to file a grievance and have one heard? What is the time table for the procedure?
56. How often do you visit physicians on -site to explain contracts and contract changes? Please address
Monroe County specifically.
57. How many physicians have you terminated from Monroe and Miami -Dade Counties in 2016 and 2017
who failed to maintain credentialing standards and how many have been terminated due to quality
assurance reasons?
58. Please describe your company's process in notifying the client and participants of changes in your
company's provider network. Please provide recent communications.
59. What has been the percentage of turnover experienced for the past three years in Monroe and Miami -
Dade Counties for the following medical providers:
PPO Network
2015
Monroe
2015
Miami -Dade
2016
Monroe
2016
Miami -Dade
2017
Monroe
2017
Miami -Dade
PCPs
Specialists
Hospitals
HMO Network
2015
Monroe
2015
Miami -Dade
2016
Monroe
2016
Miami -Dade
2017
Monroe
2017
Miami -Dade
PCPs
Specialists
Hospitals
60. What percentage of PCPs in your HMO network are "closed" and not accepting new members? In
Monroe County? In Miami -Dade County?
61. Please describe how your company handles the following situation:
A member is currently enrolled as a patient in the employer's current carrier's PPO network. The PCP
practice is closed to new patients in your HMO network. The employer changes medical carriers and the
member enrolls in the new HMO plan at open enrollment. The member's PCP is in the new carrier
network, the member wishes to remain with his current provider and enrolls in the new HMO medical plan
requesting the current PCP.
Is the member considered an existing patient when they enroll with the new carrier, or is the member
considered a new patient and denied access to this PCP?
29
Please explain in detail how your company and PCP contract address this issue.
62. Does your company plan to add any new PCP's and/or specialists to the Monroe County network? If yes,
please provide information on any new contracts or negotiations for Monroe County.
63. Is your company currently, or with in the next 12 months, negotiating any existing contracts with any
practice groups of PCPs or specialists? Yes or No.
If yes, Please provide all pertinent information concerning the practice group, dates of contract,
possible termination dates.
64. Please provide the names of all the hospitals in Monroe County that your company will be negotiating
new contracts with in the next 24 months?
65. Please provide the names of all the PCP or specialist groups in Monroe County that your company will be
negotiating new contracts with in the next 24 months?
66. Please provide the names of all the ancillary medical providers in Monroe County that your company will
be negotiating new contracts with in the next 24 months?
67. How does your contract handle the large up front deductible associated with the CDHPs? Do the
providers collect the deductible at time of service or are they required to submit a claim form for
processing and wait to bill at a later date?
30
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XXX-XX-7355
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.........................................................................................................................................
MARINERS HOSPITAL
2
XXX-XX-5661
LOWER KEYS MEDICAL CENTER
3
XXX-XX-0342
BAPTIST HOSPITAL OF MIAMI INC
4
XXX-XX-6017
U. OF M. HOSPITALS & CLINICS - NCCH
5
XXX-XX-8499
NICKLAUS CHILDREN'S HOSPITAL
6
XXX-XX-2594
SOUTH MIAMI HOSPITAL
7
XXX-XX-4424
MOUNT SINAI MEDICAL CENTER
8
XXX-XX-8571
UNIVERSITY OF MIAMI HOSPITAL
9
XXX-XX-4771
FISHERMEN'S HOSPITAL, INC.
10
XXX-XX-2993
HOMESTEAD HOSPITAL INC
11
XXX-XX-4427
VETERANS ADMINISTRATION MEDICAL CENTER
12
XXX-XX-4803
SURGERY CENTER OF KEY WEST LLC
13
XXX-XX-8452
WEST KENDALL BAPTIST HOSPITAL
14
XXX-XX-4880
CLEVELAND CLINIC FLORIDA HEALTH SYSTEM NONPROFIT
15
XXX-XX-6294
INDIAN RIVER MEMORIAL HOSPITAL
16
XXX-XX-2597
MEM HERMANN HOSPITAL
17
XXX-XX-3947
JACKSON MEMORIAL HOSPITAL
18
XXX-XX-5926
DOCTORS HOSPITAL
19
XXX-XX-1004
KEY WEST DIALYSIS
20
XXX-XX-6803
FLORIDA HOSPITAL DELAND
21
XXX-XX-4973
MEMORIAL HOSPITAL WEST
22
XXX-XX-8215
CORAL GABLES HOSPITAL, INC.
23
XXX-XX-3357
MEDICAL ARTS SURGERY CTR
24
XXX-XX-1921
THE ADOLESCENT TREATMENT CENTER OF THE PALM BEA(
25
XXX-XX-3818
HEALTHSOUTH REHABILITATION HOSP OF MIAMI LLC
26
XXX-XX-4459
FLORIDA HOSPITAL MEDICAL CENTER
27
XXX-XX-4129
ANNE BATES LEACH EYE HOSPITAL
28
XXX-XX-6841
GALLOWAY ENDOSCOPY CENTER
29
XXX-XX-8200
MARY IMMACULATE HOSPITAL INC
30
XXX-XX-3740
REGIONAL MED CTR BAYONET POINT
31
XXX-XX-7200
WAR MEMORIAL HOSPITAL INC
32
XXX-XX-3242
DENVER HEALTH MEDICAL CEN
33
XXX-XX-9484
ST VINCENTS MEDICAL CENTER SOUTHSIDE
34
XXX-XX-4812
LEE MEMORIAL HOSPITAL
35
XXX-XX-5576
THE WATERSHED INC ACT 11
36
XXX-XX-2066
FISHERIVIENS COMMUNITY HOSPITAL
37
XXX-XX-5152
WEST COAST RECOVERY CENTE
38
XXX-XX-1957
PHYSICIANS REGIONAL MEDICAL CENTER- PINE RIDGE
39
XXX-XX-1118
UNIVERSITY OF TEXAS MID ANDERSON
40
XXX -XX -3874
KALISPELL REGIONAL HOSPITAL
41
XXX -XX -4973
MEMORIAL REGIONAL HOSPITAL
42
XXX -XX -0078
KENDALL REGIONAL MEDICAL CENTER
43
XXX -XX -9921
LARKIN COMMUNITY HOSPITAL
44
XXX -XX -5661
LOWER KEYS MEDICAL CENTER - PSYCH UNIT
45
XXX -XX -7368
SURGICAL PARK CENTER LTD
46
XXX -XX -2389
PLANTATION GENERAL HOSPITAL
47
XXX -XX -3947
JACKSON SOUTH MEDICAL CENTER
48
XXX -XX -3252
JOHNS HOPKINS ALL CHILDRENS HOSPITAL
49
XXX -XX -1853
HARBOR VILLAGE INC
50
XXX -XX -5553
FLORIDA HOSPITAL HEARTLAND MEDICAL CTR
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33070
5900 COLLEGE RD
KEY WEST
FL
33040
8900 N KENDALL DRIVE
MIAMI
FL
33176
1475 NW 12TH AVE
MIAMI
FL
33136
3100 SW 62ND AVENUE
MIAMI
FL
33155
6200 SW 73RD ST
MIAMI
FL
33143
4300 ALTON ROAD
MIAMI BEACH
FL
33140
1400 NW 12TH AVENUE
MIAMI
FL
33136
3301 OVERSEAS HWY
MARATHON
FL
33050
975 BAPTIST WAY
HOMESTEAD
FL
33033
1201 NW 16TH ST
MIAMI
FL
33125
931 TOPPINO DR
KEY WEST
FL
33040
9555 SW 162ND AVE
MIAMI
FL
33196
3100 WESTON ROAD
WESTON
FL
33331
1000 36TH STREET
VERO BEACH
FL
32960
PO BOX 301208
DALLAS
TX
75303
1611 NW 12TH AVENUE
MIAMI
FL
33136
5000 UNIVERSITY DRIVE
CORAL GABLES
FL
33146
1122 N ROOSEVELT BLVD
KEY WEST
FL
33040
701 W PLYMOUTH AVENUE
DELAND
FL
32720
703 N FLAMINGO ROAD
PEMBROKE PINES
FL
33028
3100 S DOUGLAS ROAD
CORAL GABLES
FL
33134
8940 N KENDALL DR
MIAMI
FL
33176
4445 PINE FOREST DR
LAKE WORTH
FL
33463
20601 OLD CUTLER RD
MIAMI
FL
33189
601 E ROLLINS ST
ORLANDO
FL
32803
900 NW 17TH ST
MIAMI
FL
33136
7500 SW 87TH AVENUE
MIAMI
FL
33173
2 BERNARDINE DRIVE
NEWPORT NEWS
VA
23602
14000 FIVAY ROAD
HUDSON
FL
34667
1 HEALTHY WAY
BERKELEY SPRING
WV
25411
PO BOX 677920
DALLAS
TX
75267
4201 BELFORT ROAD
JACKSONVILLE
FL
32216
2776 CLEVELAND AVENUE
FORT MYERS
FL
33901
1 WATERSHED WAY
BOYNTON BEACH
FL
33426
3301 OVERSEAS HWY
MARATHON
FL
33050
785 GRAND AVE STE 220
CARLSBAD
CA
92008
6101 PINE RIDGE ROAD
NAPLES
FL
34119
PO BOX 4434
HOUSTON
TX
77210
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3501 JOHNSON STREET
HOLLYWOOD
FL
33021
11750 SW 40TH ST
MIAMI
FL
33175
7031 SW 62ND AVENUE
SOUTH MIAMI
FL
33143
1200 KENNEDY DR
KEY WEST
FL
33040
9100 SW 87TH AVE
MIAMI
FL
33176
401 NW 42ND AVENUE
PLANTATION
FL
33317
9333 SW 152ND ST
MIAMI
FL
33157
501 6TH AVE S FL 1
SAINT PETERSBURG
FL
33701;
9198 NW 8TH AVENUE
MIAMI
FL
33150
4200 SUN N LAKE BOULEVARD
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FL
33872
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$1,862,650.43
ACUTE CARE HOSPITAL
343
828
$1,774,498.68
ACUTE CARE HOSPITAL
58
118
$960,392.48
SPECIAL CANCER HOSPITAL
34
197
$792,800.71
CHILDRENS HOSPITAL
30
92
$587,614.24
ACUTE CARE HOSPITAL
34
49
$522,550.08
ACUTE CARE HOSPITAL
18
27
$277,841.35
ACUTE CARE HOSPITAL
17
58
$242,944.90
CRITICAL ACCESS HOSPITAL
129
247
$185,568.79
ACUTE CARE HOSPITAL
29
50
$183,643.76
V.A. HOSPITAL
39
237
$156,393.02
AMBULATORY SURGICAL CENTEF
89
127
$115,507.35
ACUTE CARE HOSPITAL
10
11
$104,793.75
ACUTE CARE HOSPITAL
17
62
$99,144.11
ACUTE CARE HOSPITAL
4
47
$87,796.90
1
8
$87,720.24
ACUTE CARE HOSPITAL
15
54
$82,592.67
ACUTE CARE HOSPITAL
8
17
$79,226.54
DIALYSIS
5
91
$75,074.81
ACUTE CARE HOSPITAL
2
10
$68,655.64
ACUTE CARE HOSPITAL
10
15
$51,607.99
ACUTE CARE HOSPITAL
1
1
$47,750.55
AMBULATORY SURGICAL CENTEF
10
11
$42,612.60
RESIDENTIAL TREATMENT FACILI
1
30
$33,251.42
REHABILITATION HOSPITAL
2
2
$30,961.00
ACUTE CARE HOSPITAL
10
27
$30,593.87
ACUTE CARE HOSPITAL
17
34
$30,377.75
AMBULATORY SURGICAL CENTEF
10
10
$29,822.70
1
1
$27,963.98
ACUTE CARE HOSPITAL
1
2
$26,067.89
1
2
$25,992.71
2
8
$25,494.27
ACUTE CARE HOSPITAL
1
3
$25,126.70
ACUTE CARE HOSPITAL
6
17
$22,104.97
SUBSTANCE ABUSE FACILITY
1
4
$21,467.41
CRITICAL ACCESS HOSPITAL
12
12
$20,505.26
1
21
$19,483.16
ACUTE CARE HOSPITAL
3
3
$18,869.38
1
7
$17,055.84
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ACUTE CARE HOSPITAL
8
13
$15,322.68
ACUTE CARE HOSPITAL
4
5
$15,074.00
ACUTE CARE HOSPITAL
3
5
$14,760.08
PSYCHIATRIC HOSPITAL
3
3
$14,312.50
AMBULATORY SURGICAL CENTEF
3
3
$14,093.22
ACUTE CARE HOSPITAL
3
5
$13,957.83
ACUTE CARE HOSPITAL
6
11
$13,427.44
CHILDRENS HOSPITAL
1
10
$13,320.16
SUBSTANCE ABUSE FACILITY
1
27
$13,028.28
ACUTE CARE HOSPITAL
10
34
$13,020.33
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C.19.e
EXHIBIT D - BENEFIT COMPARISON
MONROE COUNTY BOCC - 2018 BENEFIT GRID
OPTION 1- EXISTING PLAN 03559
Definitions: DED • annual deductible
PAD - per admission deductible
PVD - per visit deductible
BPM - benefit period maximum
LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL
Cost Sharing
Maximums shown ace Per Benefit Period (BPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Deductible (DED) (Per Person) Ind /Family
In- Network
$400 i$800
Out -of- Network
Combined in and out of network
Coinsurance (Member Responsibility)
In- Network
25%
Out -of- Network
55%
Out of Pocket Maximum (Per Person)
Includes Coins, Copays, DED,
Hospital PAD, and ER PVD
In- Network
$7,1501$14,300
Out -of- Network
Combined in and out of network
Lifetime Maximum
Professional Provider Services
No Maximum
Allergy Injections
In- Network Family Physician
$10
In- Network Specialist
$10
Out -of- Network
DED + 55%
E- Office Visit Services
In- Network Family Physician
$10
In- Network Specialist
$10
Out -of- Network
DED + 55%
Office Visits
In- Network Family Physician
$30 FP
In- Network Specialist
$50 SP
All Services other than office visit
DED + 25%
Out -of- Network
DED + 55%
All Services other than office visit
DED + 55:0
Provider Services at Hospital and ER
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -of- Network
DED + 25%
Provider Services at Other Locations
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25°I
Out -of- Network
DED + 55%
1 of s Packet P9. 566
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C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Preventive Care
Adult Wellness Office Services
In- Network Family Physician
$0
In- Network Specialist
$0
Out - Network
55% (No DED)
Colonoscoples (Routine)
Age 50+ then Frequency Schedule
Applies
In- Network
$0
Out-of-Network
$0
Mammograms (Routine)
In-Network
$0
Out -of- Network
$0
Well Child Office Visits (No BP M)
In - Network Family Physician
$0
In- Network Specialist
$0
Out -of- !Network
Emergency/UrgentfConvenient Care
55% (No DED)
Ambulance Maximum (per day combined ground, air
and water)
In- Network
DED + 25%
Out -of- Network
DED + 25%
Convenient Care Centers (CCC)
In- Network
$25
Out -of- Network
DED + 55%
Emergency Room Facility Services
Per Visit Deductible (PVD - Waived if Admitted)
(also see Professional Provider Services)
In- Network
$300 PVD + DED + 25 1 .'0
Out -of- Network
$300 PVD + DED + 25%
Urgent Care Centers (U CC)
In-Network - Per Visit
$50
All Services other than office visit
DED + 25%
Out -of- Network
DED + $50
All Services other than office visit
DED + 25%
o therwise
to faci li ty services. See Professional Provi
Ambulatory Surgical Center
In- Network
DED + 25%
Out -cf- Network
DED + 55%
Independent Clinical Lab
In- Network
$10
Out -cf- Network
DED + 55%
Independent Diagnostic Testing Facility -
Xrays and AIS (includes Physician Services)
In- Network - Advanced Imaging Services (AIS)
DED + 25%
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C.19.t=
Period Cost Sharing
Maximums shown are Per Benefit -
noted
Offer
Exact Benefit
Closest Alternative
Inpatient Hospital (per admit)
Per Admission Deductible (PAD)
In-Network
$150 PAD + DED + 25%
Out -of- Network
$150 PAD + DED + 55%
Inpatient Rehab Maximum
30 Days
Outpatient Hospital (per visit)
In- Network
DED + 25%
Out -of- Network
DED + 55%
Therapy at Outpatient Hospital
In- Network
DED + 25%
Out -of- Network
DED + 55%
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization
Option 1 - $150 PAD + DED + 25%
In- Network
Option 2 - $150 PAD + DED + 25%
Out -of- Network
5150 PAD + DED + 55%
Outpatient Hospitallzatlon (per visit)
Option 1 DED + 25%
In- Network
Option 2 - DED + 25%
Out -of- Network
DED + 55%
Provider Services at Hospital and ER
In- Network Family Physician or Specialist
DED + 25%
Out -of- Network Provider
DI=D + 25%
Physician Office Visit
In- Network Family Physician or Specialist
$30
All Services other than office visit
DED + 25%
Out -of- Network Provider
DED + 55%
All Services other than office visit
DED + 55%
Emergency Room Facility Services (per visit)
In- Network
$300 PVD + DED + 25%
Out -of- Network
5300 PVD + DED + 25%
Provider S a ces at Lo cation s of er th an H ospi tal
and ER
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -of- Network Provider
DED + 55%
Other Special SerAces and Locations
Advanced Imaging Services in Physician's Office
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -of- Network
DED + 55%
Birthing Center
in- Network
DED + 25%
Out -cf- Network
DED + 55%
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S of 6 Packet Pg. 570
C.19.e
Period Cost Sharing
Maximums shown are Per Benefit (BPM) unless
noted
Current Benefits
Yes, Can Offer
ExactBenefit
No, Cannot Offer
Closest Alternative
Diabetic Equipment and Supplies'
Pharmacy benefit is carved out Diabetic supplies are
covered under WE
Diabetic Equipment is also covered under DME
In- Network
DED + 25%
Out -of- Network
DED + 55%
Durable Medical Equipment, Prosthetics, Orthotics
No Maximum
BPM
In- Network
DED + 25%
Out- cf-Network
DED + 55%
Home Health Care BPM
40 Visits
In- Network
DED + 25%
Out -of- Network
DED + 55%
Hospice LTM
No Maximum
In- Network
DED + 25%
Out -of- Network
DED + 55%
Outpatient Therapy and Spinal Manipulations BPM
50 Visits (Includes up to 26 Spinal
Manipulations)
In- Network
DED + 25%
Out -of- Network
DED + 55%
Skilled Nursing Facility BPM
No Maximum
In- Network
DED + 25%
Out -of- Network
DED + 55%
Medical Pharmacy (Provider- Administered
$200 monthly OOP Max
Medications) **
Monthly OOP Max includes the drug cost share only.
Physician Services are in addition to drug costs with a
separate cost share.
In Network
20% (No DED)
Out -of- Network
DED + 50%
T
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6 of 6 Packet Pg. 571
C.19.e
EXHIBIT D - BENEFIT COMPARISON
MONROE COUNTY BOCC - 2018 BENEFIT GRID
OPTION 2 - HSA COMPATIBLE HDHP - NEW 1/1/18
Definitions: DED - annual deductible
PAD - per admission deductible
PVD - per visit deductible
RPM - benefit period maximum
LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL
Cost Sharing
unless noted
HDHP 208
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Deductible (DED) (Per Person) IndlFamlly
The deductible muse be met
before any benefit is payable
In- Network
$2,000 1 $4,600
Out -of- Network
$4.0D0 1 58.00D
Coinsurance (Member Responsibility)
In- Network
20%
Out -of - Network
50%
Out of Pocket Maximum (Per Person)
Includes Deductible, Copays,
and Coinsurance
In- Network
$6,6501$13,300
Out -of- Network
Lifetime Maximum
No Maximum
Allergy Injections
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
50%
E- Office Visit Services
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
50%
Office Visits
In- Network Family Physician
20%
In- Network Specialist
20%
All Services other Ihan office visit
20%
Out -of- Network
50%
All Services other than office visit
50%
Provider Services at Hospital
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
20%
Provider Services at Other Locations
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
50%
Radiology, Pathology and Anesthesiology Provider
Services at Hospital or Ambulatory Surgical Center
In- Network Specialist
20%
Out -of- Network
20%
1 of 4 Packet Pg. 572
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (8PM)
unless noted
Preventive Care
Proposed HDHP 2018
Yes. Can Offer
ExactBenefit
No, Cannot Offer
Closest Alternative
Adult Wellness Office Services
In- Network Family Physician
50
In- Netwcrk Specialist
50
Out -of- Network
50%
Colonoscoples (Routine)
Age 50+ then Frequency Schedule
Applies
In- Network
$0
Out -of- Network
so
Mammograms (Routine)
In- Network
$0
Out-of-Network
$0
Well Child Office Visits
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
50%
Ambulance Maximum (per day combined ground, air
and water)
In- Network
20%
Out -of- Network
20%
Convenient Care Centers (CCC)
In- Network
20%
Out -of - Network
50%
Emergency Room Facility Services
In- Network
20%
Out -of- Network
20%
Urgent Care Centers (UCC)
in- Network - Per Visit
20%
All Services other than office visit
20%
Out -of- Network
2
All Services other than office visit
20%
addition to facility services. See Professional Provider
Ambulatory Surgical Center
In- Network
20%
Out -of- Network
50%
Independent Clinical Lab
In- Network
20%
Out -of- Network
50%
Independent Iiagnostic Testing Facility -
Xrays and AIS (Includes Physician Services)
In- Network - Advanced Imaging Services (AIS)
20%
In- Network - Other Diagnostic Services
2010
Out -of- Network
50%
T
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2 of 4 Packet Pg. 573
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM)
unless noted
Proposed HDHP 20118
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Inpatient Hospital (per admit)
Per Admission Deductlhle (PAD)
In- Network
20%
Out -of- Network
50%
Inpatient Rehab Maximum
30 Days
Outpatient Hospital (per visit)
In- Network
20%
Out -ot- Network
501,
Therapy at Outpatient Hospital
In- Network
20%
Out-of-Network
MENTAL HEALTH AND SUBSTANCE ABUSE
50%
Inpatient Hospitalization
In- Network
20°%
Out -of- Network
50%
Outpatient Hospitalization (per visit)
In- Network
20%
Out -of- Network
50%
Provider Services at Hospital and ER
In- Network Family Physician or Specialist
20%
Out -of- Network Provider
2010
Physician Office Visit
ln- Network Family Physician or Specialist
20%
All Services other than office visit
20%
Out -of- Network Provider
50%
All Services other than office visit
50%
Emergency Room Facility Services (per visit)
In- Network
20°I
Out -of- Network
20%
Provl d er Se rvices at Locations other than H os Pita l
and ER
In- Network Family Physician
20%
Out--of-Network Provider
Other Spec lal Services and Locations
50%
Advanced Imaging Services in Physician's Office
In- Network Family Physician
20%
Out -of- Network
50%
Birthing Canter
In- Network
20%
Out -of - Network
50%
T
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61
7
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3 of 4 Packet Pg. 574
C.19.e
Cost s�aring
Maximums shown are Per Benefit Period (BPM)
unless noted
Proposed HDHP 2018
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Diabetic Equipment and Supplies'
Pharmacy benefit is carved aut Diabetic supplies are
covered under DME
Diabetic Equipment is also covered under DME
In- Network
20%
Out -of- Network
50%
Durable Medical Equipment, Prosthetics, Orthotics
No Maximum
BPM
In- Network
20%
Out -of- Network
50%
Home Health Care BPM
40 Visits
In- Network
20%
Out -of- Network
50°I
Hospice LTM
No Maximum
In- Network
20%
Out -of- Network
50%
Outpatient Therapy and Spinal Manipulations BPM
50 Visits (Includes up to 26
Spinal ManipulaVons)
In- Network
20%
Cut -of- Network
50%
Skilled Nursing Facility BPM
No Maximum
In- Network
20%
Out -of- Network
50%
Medical Pharmacy (Provider-Administered
$200 monthly OCP Max
Medications) "
Monthly COP Max includes the drug cost share only.
Physician Services are in addition to drug costs with a
separate cost share.
In Network
20%
Out -of- Network
50%
T
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4 of 4 Packet P9. 575
C.19.e
EXHIBIT ❑ - BENEFIT COMPARISON
MONROE COUNTY BOCC - 2018 BENEFIT GRID
OPTION 3 - EXISTING PLAN 03555 (HMO -in network only)
Definitions: DED- annual deductible
PAD- per admission deductible
PVD - per visit deductible
BPM - benefit period maximum
LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL
Period Cost Sharing
Maximums shown are Per Benefit -
noted
ExactBenefit
Offer
Closest Alternative
Deductible (DED) (Per Person) IndlFamily
In- Network
$4001$800
Out -of- Network
NIA
Coinsurance (Member Responsibility)
In- Network
25%
Out -of- Network
NIA
Out of Pocket Maximum (Per Person)
Includes Coins, Copays. DED,
Hospital PAD, and ER PVD
In- Network
$7,1501$14.300
Out -of- Network
WA
Lifetime Maxlmum
Protessional Provider Services
No Maximum
Allergy Injections
In- Network Family Physician
$10
In- Network Specialist
$10
Out -of- Network
NIA
E- Office VlsIt Services
In- Network Family Physician
$1 D
In- Network Specialist
$10
Out -of- Network
N/A
Office Visits
In- Network Family Physician
$30 FP
In- Network 5peoialist
$50 SP
All Services other than office visit
DED + 25%
Out -of- Network
MA
All Services other than office visit
NIA
Provider Services at Hospital and ER
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -of- Network
NIA
Provider Services at Other Locations
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -of- Network
WA
1 of 6 Packet P9. 576
C.19.e
T
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2of6
Packet Pg. 577
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Preventive Care
C u rrent B e nef its
Yes, Can Offer
ExactBenefit
No, Cannot Offer
Closest Alternative
Adult Wellness Office Services
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
WA
Colonoscopies (Routine)
Age 50+ then Frequency Schedule
Applies
In- Nelwark
$Q
Out -of- Network
NIA
Mammograms (Routine)
In- Network
$0
Out -of- Network
NiA
Well Child Office Visits (No BPM)
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
Einergency/UrgentiConvenient Care
NIA
Ambulance Maximum (per day combined ground, air
and water)
In- Network
DED + 2510
Out -of- Network
NIA
Convenient Care Centers (CCC)
In- Network
$25
Out -of- Network
NIA
Emergency Room Facility Services
Per Visit Deductible (PVD - Waived if Admitted)
(also see Professional Provider Services)
In- Network
$300 PVD + DED + 25%
Out -af- Network
N: A
Urgent Care Centers (UCC)
In- Network - Per Visit
$50
All Services other than office visit
DED + 25%
Out -of- Network
$50
All Services other than office visit
I
DED + 25%
Unless otherwise noted r, physician services are in addition
.
Ambulatory Surgical Center
In- Network
DED + 25%
Out -of- Network
N1A
Independent Clinical Lab
In- Network
$10
Out -of- Network
NIA
Independent Diagnostic Testing Facility -
Xrays and AI5 (Includes Physician Services)
In- Network - Advanced Imaging Services (AIS)
DED + 25%
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3 of 6 Packet Pg. 578
C.19.e
T
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4o #6
Packet P9. 579
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Inpatient Hospital (per admit)
Per Admission Deductible (PAD)
In- Network
$150 PAD + DED + 25 0 %
Out -of- Network
NIA
Inpatient Rehab Maximum
30 Days
Outpatient Hospital (per visit)
In- Network
DED + 25 °/n
Out -of- Network
NIA
Therapy at Outpatient Hospital
In- Network
DED + 25%
Out-of-Network
WA
MENTAL HEALTH AND SUBSTANCE ABUSE
Inpatient Hospitalization
Option 1 - $150 PAD + DED + 2510
In- Network
Option 2 - $1511 PAD + DEO + 25%
Out -of- Network
NIA
Outpatient Hospitalization (per visit)
Option 1 DED + 25%
In- Network
Option 2 - DED + 25%
Out-of-Network
NIA
Provider Services at Hospital and ER
In- Network Family Physician or Specialist
DED + 25%
Out -of- Network Provider
NIA
Physician Office Visit
In- Network Family Physician or Specialist
$30
All Services other than office visit
DED + 25%
Out -of- Network Provider
NIA
All Services other than office visit
NIA
Emergency Room Facility Services (per visit)
In- Network
$300 PVD + DED + 25%
Out -of- Network
$300 PVD + DED + 25%
ro der Servi ces at Locatl on other than H osp
and ER
In- Network Family Physician
DER + 25%
In- Network Specialist
DED + 25%
Out -of- Network Provider
NIA
Other Special Services and Locations
Advanced Imaging Services in Physician's Office
In- Network Famiiy Physician
DED + 25%
In- Network Specialist
DIED + 25%
Out -of- Network
NIA
Birthing Center
In- Network
DED + 25%
Out -of - Network
NIA
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5 of 6 Packet Pg. 580
C.19.e
Period Cost Sharing
Maximums shown are Per Benefit (BPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Diabetic Equipment and Supplies'
Pharmacy benefit is carved out Diabetic supplies are
covered under DME
Diabetic Equipment is also covered under DME
In- Network
DED + 25%
Out -of- Network
NIA
Durable Medical Equipment, Prosthetics, Orthotics
No Maximum
BPM
In- Network
DED + 25%
Out -of- Network
NIA
Home Health Care BPM
40 Visits
In- Network
DED + 25%
Out -of- Network
NIA
Hospice t.TM I
No Maximum
In- Network
DED + 25%
Out -of- Network
NIA
Outpatient Therapy and Spinal Manipulations BPM
50 Visits (Includes up to 26 Spinal
Manipulations)
In- Network
DED + 25°i
Skilled Nursing Facility BPM
No Maximum
In- Network
DED + 25%
Out -of - Network
NIA
Medical Pharmacy (Provider- Administered
$200 monthly OOP Max
Medications) "
Monthly OOP Max includes the drug cost share only.
Physician Services are in addition to drug costs with a
separate cost share.
In Network
20% (No DED)
Out -of- Network
NIA
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6 of 6 Packet P9. 581
C.19.e
EXHIBIT ❑ - BENEFIT COMPARISON
MONROE COUNTY BOCC - 2018 BENEFIT GRID
OPTION 4 - HIGH DEDUCTIBLE HMO - PROPOSED
Definitions: DED - annual deductible
PAD- per admission deductible
PVD - per visit deductible
BPM - benefit period maximum
LTIVI - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Proposed HDHP 2018
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Deductible (DIED) (Per Person) Ind /Family
The deductible must be met
before any benefit is payable
In- Network
$2,0001$4,000
Coinsurance (Member Responsibility)
!n- Network
20%
Out-of-Network
NIA
Out of Pocket Maximum (Per Person)
includes Deductible, Copays, and
Coinsurance
In- Network
$6,6501$13,300
Out -of- Network
NIA
Lifetime Maximum
'Professional Provider Services
No Maximum
Allergy Injections
In- Network Family Physician
20%
In- Network Specialist
20%
Out -af- Network
WA
E- Office Visit Services
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
NIA
Office Visits
In- Network Family Physician
20%
In- Network Specialist
20%
All Services other than office visit
20%
Provider Services at Hospital and ER
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
NIA
Provider Services at Other Locations
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network
NIA
Radiology, Pathology and Anesthesiology Provider
Services at Hospital or Ambulatory Surgical Center
In- Network Specialist
20%
Clut -of- Network
NIA
1 of 5 Packet Pg. 582
C.19.e
Period Cost Sharing
Maximums shown are Per Benefit (BPM) unless
noted
Preventive Care
Proposed HDHP
Exact Benefit
Closest Alternative
Adult Wellness Office Services
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
N. +A
Colonoscopies (Routine)
Age 50+ then Frequency Schedule
Applies
In- Network
$0
Out -of- Network
NIA
Mammograms (Routine)
In- Network
$0
Out -of- Network
N ?A
Well Child Office Visits (No BPM)
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
NIA
Ambulance Maximum (per day combined ground, air
and water)
In- Network
20%
Out -of- Network
20%
Convenient Care Centers (CCC)
In- Network
20%
Out -of- Network
NIA
Emergency Room Facility Services
Per Visit Deductible (PVD - Waived if Admitted)
(also see Professional Provider 5ervicesy
In- Network
20%
Out -cf- Network
20%
Urgent Care Centers (UCC)
In- Network - Per Visit
20%
All Services other than office visit
20%
Out -of- Network
20%
All Services other than office visit
20%
Unless otherwi.se noted, physician services are In addition
Ambulatory Surgical Center
In- Network
20%
Out -of- Network
NIA
Independent Cllnlcat Lab
In- Network
20%
Out -0f - Network
NIA
Independent Diagnostic Testing Facility -
Xrays and AIS (Includes Physician Services)
In- Network - Advanced Imaging Services (AIS)
20%
T
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41
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2 of 5 Packet Pg. 583
C.19.e
T
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Packet Pg. 584
C.19.e
Cost Sharing
- e Per Benefit Period (BPM) unless maximums shown ai
noted
Proposed
•
Exact Benefit
No,CannotOffer
Closest Alternative
Inpatient Hospital (per admit)
Per Admission Deductible (PAD)
In- Network
20%
Out -of- Network
NIA
Inpatient Rehab Maximum
30 Days
Outpatient Hospital (per visit)
In- Network
20%
Out -of- Network
NIA
Therapy at Outpatient Hospital
In- Network
20%
Out -of- Network
MENTAL HEALTH AND SUBSTANCE ABUSE
NIA
Inpatient Hospitalization
In- Network
20%
Out -cf- Network
NIA
Outpatient Hospitalization (per visit)
20%
In- Network
Cut-of-Network
NIA
Provider Services at Hospital
In- Network Family Physician or Specialist
20%
Cut -of- Network Provider
NIA
Physician office Visit
In- Network Family Physician or Specialist
20%
All Services other than office visit
20%
Out -of- Network Provider
NIA
All Services other than office visit
NIA
Emergency Room Facility Services {per visit}
In- Network
20%
Out -of- Network
20%
ProAder Services at Locations other than asp to
and ER
In- Network Family Physician
20%
In- Network Specialist
20%
Out -of- Network Provider
NIA
Other Special Services and Locations
Advanced imaging Services in Physician's Office
In- Network Family Physician
20%
In- Network Specialist
20%
Out- of- Nelwork
N/A
Birthing Center
In- Network
20%
Out -of- Network
NIA
T
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4 of s Packet Pg. 585
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Proposed HDHP 2018
Yes,CanOffer
ExactSenefit
No,CannotOffer
Closest Alternative
Diabetic Equipment and Supplies`
Pharmacy benefit is carved out Diabetic supplies are
covered under DME
Diabetic Egwornent is also covered under DME
In- Network
20%
Out -af- Network
NIA
Durable Medical Equipment, Prosthetics, Orthotics
No Maximum
BPM
In- Network
20%
Out -of- Network
NIA
Home Health Care BPM
40 Visits
In- Network
20%
Out -of- Network
NIA
Hospice LTM
No Maximum
In- Network
20%
Out -of- Network
NIA
Outpatient Therapy and Spinal Manipulations BPM
50 Visits (includes up to 26 Spinal
Manipulations)
In- Network
20%
Skilled Nursing Facility BPM
No Maximum
In- Network
20%
Out -of- Network
NIA
Medical Pharmacy (Provider- Administered Medication)
$240 monthly OOP Max
Monthly OOP Max includes the drug cost share only.
Physician Services are in addition to drug costs with a
separate cost share.
In Network
20%
Out -of- Network
NIA
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5 of 5 Packet Pg. 586
C.19.e
EXHIBIT D - BENEFIT COMPARISON
MONROE COUNTY BOCC - 2018 BENEFIT GRID
OPTION 5 PPO with EGWP - BASED ON EXISTING PLAN 03559
Definitions: QED - annual deductible
PAD - per admission deductible
PVD - per Visit deductible
BPM - benefit period maximum
LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL
Period Cost Sharing
Maximums shown are Per Benefit Benefits
noted
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Deductible (DED) (Per Person) Individual Coverage Only
In- Network
5460
Out -of- Network
Coinsurance (Member Responsibility)
In- Network
25%
Out -of- Network
55%
Out of Pocket Maximum (Per Person)
Includes Coins, Copays, DED,
Hospital PAD, and ER PVD
In- Network
$3.575
Out -of- Network
$3,575
Lifetime Maximum
Professional Provider Services
No Maximum
Allergy Injections
In- Network Family Physician
$10
In- Network Specialist
$10
Out -of- Network
DED + 55%
E -Office Visit Services
In- Network Family Physician
$10
In- Network Specialist
$10
Out -of- Network
DED + 55%
Office Visits
In- Network Family Physician
$30 FP
In- Network Specialist
$50 SP
All Services other than office visit
RED + 25%
Out -of- Network
DED + 55%
All Services other than office visa
QED + 5510
Provider Services at Hospital and ER
In- Network Family Physician
QED + 25%
In- Network Specialist
DED + 25%
Out -of- Network
OED + 25%
Provider Services at Other Locations
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25 %
Out -of- Network
DED + 55%
1 of 6 Packet Pg. 587
C.19.e
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2 of 6
Packet P9. 588
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
rioted
Preventive Care
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Adult Wellness Office Services
In- Network Family Physician
50
In- Network Specialist
$0
Out -of- Network
55% (No DED)
Colonoscoples (Routine)
Age 50+ then Frequency Schedule
Applies
In- Network
$0
Out -of- Network
$0
Mammograms tRoutine)
In-Network
s0
Out -of- Network
$0
Well Child Office Visits (No 6PM)
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
Emergency/UrgentIConvenient Care
55% (No DED)
Ambulance Maximum (per day combined ground, air
and water)
In- Network
DED + 25%
Out -af- Network
DED + 25%
Convenient Care Centers (CCC)
In- Network
$25
Out -of- Network
DED + 55
Emergency Room Facility Services
Per Visit Deductible JPVD - Waived if Admitted)
(also see Professional Provider Services)
In- Network
$300 PVD + DED + 25%
Out -of- Network
$300 PVD + DED + 25%
Urgent Care Centers (UCC)
In- Network - Per Visit
$50
All Services other than office visit
DED + 25%
Out -of- Network
DED + $50
All Services other than office visit
DTF
Unless otherwise noted, services are in addition
DEC + 25%
physician
to facility services. See Professional Provider Services.
Ambulatory Surgical Center
In- Network
DED + 25%
Out -of- Network
DED + 55%
Independent Clinical Lab
In- Network
$10
Out -of- Network
DED + 55 %
Independent 0 lag nostic Testing Facility -
Jfrays and AIS (Includes Physician Services)
1n- Network -Advanced Imaging Services (AIS)
DED + 25%
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3 of 6 Packet Pg. 589
C.19.e
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4of6
Packet P9. 590
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (51 unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Inpatient Hospital (per admit)
Per Admission Deductlble (PAD)
In- Network
$150 PAD + DED + 25°1
Out -cf- Network
$150 PAD + DED + 55%
Inpatient Rehab Maximum
30 Days
Outpatient Hospital tper visit)
In- Network
DED + 25%
Out -of- Network
DED + 55%
Therapy at Outpatient Hospital
In- Network
DED + 25%
Out -of- Network
MENTAL HEALTH ■ SUBSTANCE ABUSE
DED + 55%
Inpatient Hospitalization
Option 1 - $150 PAD + DED + 25%
In- Network
Option 2 - $150 PAD +DED + 25%
Out -of- Network
$150 PAD + DED + 55%
Outpatient Hospitalization (per visit)
Option 1 DED + 25%
In- Network
Option 2 -DED + 25 °I
Out -of- Network
DED + 55%
Provider Services at Hospital and ER
In- Network Family Physician or Specialist
DED + 25%
Out -of- Network Provider
DED + 25%
Physician Office Visit
In- Network Family Physician or Specialist
$30
All Services other than office visit
DED + 25%
Out -of- Network Provider
DED + 55%
All Services other than office visit
DED + W/o
Emergency Room Facility Services (per visit)
In- Network
$300 PVD + DED + 25%
Out -of- Network
$300 PVD + DED + 25%
ro er gervices at Locations other than Hospital
and ER
In- Network Family Physician
DED + 25 %
In- Network Specialist
DED + 25%
Out -of- Network Provider
DED + 55%
Other Special Sgrvices and Locations
Advanced Imaging Services in Physician's Office
In- Network Family Physician
DED + 25%
in- Network Specialist
DED + 25%
Out -of- Network
DED + 55%
Birthing Center
In- Network
DED + 25%
Out -of- Network
DED + 55%
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5 of 6 Packet P9. 591
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Diabetic Equipment and Supplies"
Pharmacy benefit is carved out Diabetic supplies are
covered under DME
Diabetic Equipment is also covered under DME
In- Network
QED + 25%
Out -of- Network
DED + 55%
Durable Medical Equipment, Prosthetics, Orthotics
No Maximum
BPM
In- Network
DED + 25%
Out -of- Network
DED + 55%
Home Health Care BPM
40 Visits
In- Network
DED + 25%
Out -of- Network
QED + 55 %
Hospice LTM
No Maximum
In- Network
DED + 25%
Out -of- Network
DED + 55%
Outpatient Therapy and Spinal Manipulations BPM
50 Visits (Includes up to 26 Spinal
Manipulations)
In- Network
DED + 25%
Out -of- Network
DED + 55%
Skilled Nursing Facility BPM
No Maximum
In- Network
DED + 25%
Out -of- Network
DED + 55%
Medical Pharmacy I Provider-Ad mInistered Rx) *`
$200 monthly OUP Max
Monthly OOP Max includes the drug cost share only.
Physician Services are in addition to drug casts with a
separate cost share.
In Network
20% (No OED)
but -of- Network
DED + 50%
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606 Packet P9. 592
C.19.e
EXHIBIT ❑ - BENEFIT COMPARISON
MONROE COUNTY BOCC - 2018 BENEFIT GRID
OPTION 6 HMO with EGWP - BASED on EXISTING PLAN 03559
Definitions: DED - annual deductible
PAD - per admission deductible
PVD - per visit deductible
BPM - benefit period maximum
LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless Current Benefits
noted
Yes, Can Offer
ExactBenefit
No, Cannot Offer
Closest Alternative
Deductible (DED) (Per Person) Individual Coverage Only
In- Network
$400
Out-of-Network
Coinsurance (Member Responsibility)
In- Network
25%
Out-of-Network
NIA
Out of Pocket Maximum (Per Person)
Includes Coins. Copays, DED,
Hospital PAD, and ER PVD
In-Network
$3,575
Out -of- Network
NIA
Lifetime Maximum
Professional Provider Services
No Maximum
Allergy Injections
In- Network Family Physician
$1p
In- Network Specialist
$10
Out -of- Network
NIA
E- Office Visit Servlses
In-Network Family Physician
$10
In- Network Specialist
$10
Out-of-Network
N/A
Office Visits
In- Network Family Physician
$30 FP
In- Network Specialist
S50 SP
All Services other than office visit
DIED + 25%
Out-of-Network
NIA
All Services other than office visit
MA
Provider Services at Hospital and ER
In- Network Family Physician
DED + 25%
In-Network Specialist
DED + 25%
Out -af- Network
NIA
Provider Services at Other Locations
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -of- Network
NIA
1 of 6 Packet P9. 593
C.19.e
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2nf6
Packet P9. 594
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period (BPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Preventive Care
Adult Wellness Office Services
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
NiA
Colonoscoples (Routine)
Age 54+ then Frequency Schedule
Applies
In- Network
$0
Out -of- Network
WA
Mammograms (Routine and Dx)
In- Network
$0
Out -of- Network
$0
eiI Child Office Visits (No BPM)
In- Network Family Physician
$0
In- Network Specialist
$0
Out -of- Network
NIA
Ambulance Maximum (per day combined ground, air
and watery
In- Network
DED + 25%
Out -of- Network
NIA
Convenient Care Centers (CCC)
In- Network
$25
Out -of- Network
NIA
Emergency Room Facility Services
Per Visit Deductible (PVD - Waived if Admitted)
(also see Professional Provider Services)
In- Network
$300 PVD + DED + 25%
Out -of- Network
NIA
Urgent Care Centers (UCC)
In- Network - Per Visit
$50
All Services other than office visit
DED + 25%
Out -of- Network
$50
All Services other than office visit
Unless otherwise noted, physician services are.in addition
DED + 25%
Ambulatory Surgical Center
In- Network
DED + 25%
Out-of-Network
WA
Independent Clinical Lab
In- Network
$10
Out -of- Network
NIA
independent Diagnostic Testing Facility -
Xrays and AIS (Includes Physician Services)
In- Netwerk - Advanced Imaging Services (AIS)
DED + 2510
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3 of s Packet Pg. 595
C.19.e
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4of6
Packet P9. 596
C.19.e
Cost Sharing
Maximums shown are Per Benefit Period JBPM) unless
noted
Current Benefits
Yes, Can Offer
Exact Benefit
No, Cannot Offer
Closest Alternative
Inpatient Hospital (per admit)
Per Admission Deduct €pie (PAD)
In- Network
$150 PAD + DED + 25°x.
Out -cf- Network
NIA
Inpatient Rehab Maximum
30 Days
Outpatient Hospital (per vlslQ
In- Network
DED + 25
Out -of- Network
NIA
Therapy at Outpatient Hospital
In- Network
DED + 25%
Cut-of-Network
MENTAL HEALTH ■ SUBSTANCE ABUSE
N. ?A
Inpatient Hospitalization
Option 1 - $150 PAD + DED + 25%
In- Network
Option 2 - $150 PAD + DED + 25%
Out -of- Network
N ?A
Outpatient Hospitalization (per vi sit)
Option 1 DED + 25%
In- Network
Option 2 -DED + 25
Out -of- Network
NIA
Provider Services at Hospital and ER
In- Network Family Physician or Specialist
DED + 25%
Out -of- Network Provider
WA
Physician Office Visit
In- Network Family Physician or Specialist
$30
All Services other than office visit
DED + 25%
Out -of- Network Provider
NIA
All Services other than office visit
NIA
Emergency Room Facility Services (per visit)
In- Network
$300 PVD + DED + 25
Out -of- Network
NIA
ro der SenA ces at oca cans oth er than n osp to
and ER
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25%
Out -0f - Network Provider
Other Special Serviices and Locations
N/A
Advanced imaging Services in Physician's Office
In- Network Family Physician
DED + 25%
In- Network Specialist
DED + 25
Out-of-Network
N+A
Birthing Center
In-Network
DED + 25 0 %
Out -cf- Network
NIA
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5 of 6 Packet P9. 597
C.19.e
Cost Sharing
M axi m u rn s sh own a re Per Ben efi t Period (B PM) u n I ess
noted
Current Benefits
Yes, Can Offer
ExactBenefit
No, Cannot Offer
Closest Alternative
Diabetic Equipment and Supplies`
Pharmacy benefit is carved out Diabetic supplies are
covered under DME
Diabetic Equipment is also covered under DME
In- Network
DED + 25%
Out -of- Network
N..A
Durable Medical Equipment, Prosthetics, Orthotics
No Maximum
BPM
in- Network
DIED + 25%
Out -of- Network
NIA
Home Health Care BPM
40 Visits
In- Network
DED + 25%
OW -cf- Network
N?A
Hospice LTM
No Maximum
In- Network
DED + 25%
Out-o #-Network
NIA
Outpatient Therapy and Spinal Manipulations BPM
50 Visits (Includes up to 26 Spinal
Manipulations)
In- Network
DED + 25%
Skilled Nursing Facility BPM
No Maximum
In- Network
DED + 25%
Out-of-Network
NIA
Medical Pharmacy (Prodder- Administered
$200 monthly OOP Max
Medications)'"
Monthly 00P Max includes the drug cost share only.
Physician Services are in addition to drug costs with a
separate cost share.
In Network
20% (No DED)
Out -of- Network
NIA
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Supplement to the
Blue Options
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
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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 .............................................. .............................15
CARRIERS AND CONTACT INFORMATION ................................................... .............................16
2
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
4
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 /O1; 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 /O1; 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 /O1; 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(3 0), 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 /O1; 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.
3
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.
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).
1
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 coven
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."
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).
How is 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 „healthcare, ov.
If you have questions
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:ll3.bcbsfl.corr�l slortallbcsfllaboutuslreportfraud .
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 Rx)
Toll -Free Customer Service: (800) 361 -4542
Website: www.envisionrx.co
Vision Benefits (Insured and Administered by Vision service Plan Insurance Company)
Toll -Free Customer Service: (800) 877 -7195
Website: r.vs.co
Dental Benefits (Insured and Administered by Delta Dental
Toll -free Customer Service: (800) 521 -2651
Website: www.deltadentalins.co
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: ochSO)ochsinc.co
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
BlueOptions
Schedule of Benefits — Plan 03559
Important things to keep in mind as you review this Schedule of Benefits:
• This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your
benefits can be found.
• NetworkBlue is the panel of Providers designated as In- Network for your plan. You should always
verify a Provider's participation status prior to receiving Health Care Services. To verify a Provider's
specialty or participation status, you may contact the local BCBSF office or access the most recent
BlueOptions Provider directory on our website at www.floridablue.com If you receive Covered
Services outside the state of Florida from BlueCard participating PPO Providers, payment will be
made based on In- Network benefits.
• References to Deductible are abbreviated as "DED ".
• Your benefits accumulate toward the satisfaction of Deductibles, Out -of- Pocket Maximums, and any
applicable benefit maximums based on your Benefit Period unless indicated otherwise within this
Schedule of Benefits.
Your Benefit Period ........................................................ ............................... ..........................01 /01 — 12/31
Deductible, Coinsurance and Out -of- Pocket Maximums
Benefit Description
In- Network
Out -of- Network
Deductible (DED)
$400
Per Person per Benefit Period
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
$800
Per Family per Benefit Period
Per Admission Deductible (PAD)
$150
$150
Emergency Room Per Visit Deductible (PVD)
$300
$300
Coinsurance
(The percentage of the Allowed Amount you
25%
55%
pay for Covered Services)
Out -of- Pocket Maximums
$7,150
Per Person per Benefit Period
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
$14,300
Per Family per Benefit Period
BlueOptions ASO
Plan 03559 PC 1
Amounts incurred for In- Network Services will only be applied to the amounts listed in the In- Network
column and amounts incurred for Out -of- Network Services will only be applied to the amounts listed in
the Out -of- Network column, unless otherwise indicated within this Schedule of Benefits. This includes
the Deductible and Out -of- Pocket Maximum amounts.
What applies to out -of- pocket maximums? 9 DIED
• PAD, when applicable
• Coinsurance
• Copayments
• PVD when applicable
What does not apply to out -of- pocket
maximums?
• Non - covered charges
• Any benefit penalty reductions
• Charges in excess of the Allowed Amount
Important information affecting the amount you will pay:
As you review the Cost Share amounts in the following charts, please remember:
• Review this Schedule of Benefits carefully; it contains important information concerning your share of
the expenses for Covered Services you receive. Amounts listed in this schedule are the Cost Share
amounts you pay.
• Your Cost Share amounts will vary depending upon the Provider you choose, the type of Services
you receive, and the setting in which the Services are rendered.
• Payment for Covered Services is based on our Allowed Amount and may be less than the amount
the Provider bills for such Service. You are responsible for any charges in excess of the Allowed
Amount for Out -of- Network Providers.
• If a Copayment is listed in the charts that follow, the Copayment applies per visit.
BlueOptions ASO
Plan 03559 PC 2
Office Services
A Family Physician is a Physician whose primary specialty is, according to BCBSF's records, one of the
following: Family Practice, General Practice, Internal Medicine, and Pediatrics.
Benefit Description
In- Network
Out -of- Network
Office visits and Services not otherwise outlined in
this table rendered by
Family Physicians
---------------------------------------------------------------------------------
Office visit only
--------------------------------- - - - - --
$25
---------------------------------------
DED + 55%
All Services other than office visit
DED + 25%
DED + 55%
Other health care professionals licensed to
perform such Services
---------------------------------------------------------------------------------
OfFce visit only
--------------------------------- - - - - --
$25
---------------------------------------
DED + 55%
All Services other than office visit
DED + 25%
DED + 55%
Advanced Imaging Services
(CT /CAT Scans, MRAs, MRIs, PET Scans and
nuclear cardiology)
DED + 25%
DED + 55%
---------------------------------------------------------------------------------
--------------------------------- - - - - --
---------------------------------------
DED + 55%
All other diagnostic Services (e.g., X -rays)
DED + 25%
Allergy Injections rendered by
Family Physicians
$10
DED + 55%
---------------------------------------------------------------------------------
Other health care professionals licensed to
--------------------------------- - - - - --
$10
---------------------------------------
°
DED + 55 /o
perform such Services
E- Visits rendered by
Family Physicians
$10
DED + 55%
---------------------------------------------------------------------------------
Other health care professionals licensed to
--------------------------------- - - - - --
$10
---------------------------------------
°
DED + 55 /o
perform such Services
Durable Medical Equipment, Prosthetics, and
DED + 25%
DED + 55%
Orthotics
Convenient Care Centers
$25
DED + 55%
Chiropractic Services
DED + 25%
DED + 55%
Note: Includes office and free - standing facilities
Telemedicine
$0
Not Covered
BlueOptions ASO
Plan 03559 PC 3
Medical Pharmacy
Benefit Description
In- Network
Out -of- Network
Prescription Drugs administered in the office by:
Family Physicians
20%
DED + 50%
------------------------------------------------------------------------------
Physicians other than Family Physicians and
--------------------------------- - - - - --
-----------------------------------------
other health care professionals licensed to
20%
DED + 50%
perform such Services
Out -of- Pocket Maximum per Person per Month
$200
Not Applicable
Important — The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and
is in addition to the office Services Cost Share. Immunizations, allergy injections as well as Services
covered through a pharmacy program are not considered Medical Pharmacy. Please refer to your
Benefit Booklet for a description of Medical Pharmacy.
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Plan 03559 PC
Preventive Health Services
Benefit Description
In- Network
Out -of- Network
Adult Wellness Services
Rendered by
$0
55%
Family Physicians
---------------------------------------------------------------------------------
Other health care professionals licensed to
--------------------------------- - - - - --
$0
---------------------------------------
55%
perform such Services
---------------------------------------------------------------------------------
All other locations
--------------------------------- - - - - --
$0
---------------------------------------
55%
Adult Well Woman Services
Rendered by
$0
55%
Family Physicians
---------------------------------------------------------------------------------
Other health care professionals licensed to
--------------------------------- - - - - --
$0
---------------------------------------
55%
perform such Services
---------------------------------------------------------------------------------
All other locations
--------------------------------- - - - - --
$0
---------------------------------------
55%
Child Health Supervision Services rendered by
Family Physicians
$0
55%
Other health care professionals licensed to
$0
55%
perform such Services
---------------------------------------------------------------------------------
All other locations
--------------------------------- - - - - --
$0
---------------------------------------
55%
Mammograms
$0
$0
Routine Colonoscopy
$0
$0
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Plan 03559 PC
Outpatient Diagnostic Services
Benefit Description
In- Network
Out -of- Network
Independent Clinical Lab
$0
DED + 55%
Independent Diagnostic Testing Facility
Emergency Room Visits
DED + 55%
Advanced Imaging Services (CT /CAT Scans,
Emergency Room Visits
Urgent Care Center
MRAs, MRls, PET Scans and nuclear
DED + 25%
DED + 55%
medicine)
DED + $25
All Services other than office visit
--------------------------------------------------------------------------- - - - - --
All other diagnostic Services (e.g., X -rays)
--------------------------------- - - - - --
DED + 25%
---------------------------------------
DED + 55%
Outpatient Hospital Facility
See Hospital Services
Outpatient Hospital Facility
Outpatient
Emergency and Urgent Care Services
Benefit Description
In- Network
Out -of- Network
Ambulance Services
In- Network DED + 25%
See Hospital Services
Emergency Room Visits
DED + 55%
---------------------------------------------------------------------------------
Radiologists, Anesthesiologists, and
Emergency Room Visits
Urgent Care Center
Pathologists
a) Office visit only
$25
DED + $25
All Services other than office visit
DED + 25%
DED + $25
Outpatient Surgical Services
Benefit Description
In- Network
Out -of- Network
Ambulatory Surgical Center
Facility (per visit)
DED + 25%
DED + 55%
---------------------------------------------------------------------------------
Radiologists, Anesthesiologists, and
--------------------------------- - - - - --
DED + 25%
---------------------------------------
DED + 25%
Pathologists
---------------------------------------------------------------------------------
Other health care professional Services
--------------------------------- - - - - --
DED + 25%
---------------------------------------
DED + 55%
rendered by all other Providers
See Hospital Services
Outpatient Hospital Facility
Outpatient
BlueOptions ASO
Plan 03559 PC 6
Hospital Services
*Please refer to the current Provider Directory to determine the applicable option for each In- Network
Hospital.
Important:
Certain categories of Providers may not be available In- Network in all geographic regions. This includes,
but is not limited to, anesthesiologists, radiologists, pathologists and emergency room physicians. This
Plan will pay for Covered Services rendered by a Physician in a Hospital setting (i.e., inpatient, outpatient,
or emergency room) at the In- Network benefit level. Claims paid in accordance with this note will be
applied to the In- Network DED and Out -of- Pocket Maximums.
BlueOptions ASO
Plan 03559 PC 7
In- Network
Benefit Description
Out -of- Network and
Option 1*
Option 2*
and Out -of -State
Traditional
BlueCard Participati
Providers
ng
Inpatient
Facility Services (per admission)
$150 PAD + DED + 25%
$150 PAD + DED +
55%
--------------------------------------------------------
Physician and other health care
---------------------------------------------------------------- - - - - --
DED + 25%
---------------------------------
DED + 25%
professional Services
Outpatient
Facility (per visit)
DED + 25%
DED + 55%
--------------------------------------------------------
Physician and other health care
---------------------------------------------------------------- - - - - --
DED + 25%
---------------------------------
DED + 25%
professional Services
--------------------------------------------------------
Therapy Services
---------------------------------------------------------------- - - - - --
---------------------------------
DED + 55%
DED + 25%
Emergency Room Visits
$300 PVD + DED + 25%
$300 PVD + DED +
Facility
25%
--------------------------------------------------------
Physician and other health care
---------------------------------------------------------------- - - - - --
DED + 25%
---------------------------------
DED + 25%
professional Services
*Please refer to the current Provider Directory to determine the applicable option for each In- Network
Hospital.
Important:
Certain categories of Providers may not be available In- Network in all geographic regions. This includes,
but is not limited to, anesthesiologists, radiologists, pathologists and emergency room physicians. This
Plan will pay for Covered Services rendered by a Physician in a Hospital setting (i.e., inpatient, outpatient,
or emergency room) at the In- Network benefit level. Claims paid in accordance with this note will be
applied to the In- Network DED and Out -of- Pocket Maximums.
BlueOptions ASO
Plan 03559 PC 7
Behavioral Health Services
Benefit Description
In- Network
Out -of- Network
Mental Health and Substance Dependency
Treatment Services
Outpatient
Facility Services rendered at:
Emergency Room
$300 PVD + DED + 25%
$300 PVD + DED + 25%
---------------------------------------------------------------------------------
Hospital
--------------------------------- - - - - --
DED + 25%
---------------------------------------
DED + 55%
---------------------------------------------------------------------------------
Physician Services at Hospital and ER
--------------------------------- - - - - --
DED + 25%
---------------------------------------
DED + 25%
Physician and other health care professionals
licensed to perform such Services
Family Physician office
$25
DED + 55%
a.) Office Visit Only
b.) All Services other than office visit
DED + 25%
DED + 55%
---------------------------------------------------------------------------------
Specialist office
--------------------------------- - - - - --
$25
---------------------------------------
DED + 55%
a.) Office Visit Only
b.) All Services other than office visit
DED + 25%
DED + 55%
---------------------------------------------------------------------------------
All other locations
--------------------------------- - - - - --
DED + 25%
---------------------------------------
DED + 55%
Inpatient
Facility Services
$150 PAD + DED + 25%
$150 PAD + DED + 55%
---------------------------------------------------------------------------------
Physician and other health care professionals
--------------------------------- - - - - --
---------------------------------------
DED + 25%
DED + 25%
licensed to perform such Services
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Plan 03559 PC
Benefit Maximums
Home Health Care Visits per Benefit Period ............................................................... ............................... 40
Inpatient Rehabilitation days per Benefit Period ....................................................... ............................... 30
Outpatient Therapies and Spinal Manipulations Visits (combined) per Benefit Period ......................... 50
Note: Spinal Manipulations are limited to 26 visits per Benefit Period and accumulate towards the
Outpatient Therapies and Spinal Manipulations benefit maximum. Refer to the Benefit Booklet for
reimbursement guidelines.
Skilled Nursing Facility days per Benefit Period ............................................ ............................... Unlimited
Additional Benefits /Features
Benefit Maximum Carryover
If, immediately before the Effective Date of the Group, you or your Covered Dependent were covered
under a prior group policy form issued by BCBSF or Health Options, Inc. to the Group, amounts applied
to your Benefit Period maximums under the prior BCBSF or Health Options, Inc. policy will be applied
toward your Benefit Period maximums under this plan.
BlueOptions ASO
Plan 03559 PC 9
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
Section2: What Is Covered? ......................................................... ............................2 -1
Section 3: What Is Not Covered? ............................................... ............................... 3 -1
Section 4: Medical Necessity ..................................................... ............................... 4 -1
Section 5: Understanding Your Share of Health Care Expenses .............................. 5 -1
Section 6: Physicians, Hospitals and Other Provider Options .... ............................... 6 -1
Section 7: BlueCard (Out -of- State) Program ............................ ............................... 7 -1
Section 8: Blueprint for Health Programs ................................... ............................... 8 -1
Section 9: Eligibility for Coverage ............................................... ............................... 9 -1
Section 10: Enrollment and Effective Date of Coverage ................. ...........................10 -1
Section 11: Termination of Coverage ............................................. ...........................11 -1
Section 12: Continuing Coverage Under COBRA .......................... ...........................12 -1
Section 13: Conversion Privilege ........................................ ...........................13 -1
Section 14: Extension of Benefits ....................................... ...........................14 -1
Section 15: The Effect of Medicare Coverage/ Medicare Secondary Payer
Provisions................................................................... ...........................15 -1
Section 16: Duplication of Coverage Under Other Health Plans /Programs ...............16 -1
Section 17: Claims Processing ....................................................... ...........................17 -1
Section 18: Relationship Between the Parties ................................ ...........................18 -1
Section 19: General Provisions ...................................................... ...........................19 -1
Section 20: Definitions .................................................................... ...........................20 -1
Table of Contents
Section 1: How to Use Your Benefit Booklet
This is your Benefit Booklet ( "Booklet "). It
describes your coverage, benefits, limitations
and exclusions for the self- funded Group Health
Benefit Plan ( "Group Health Plan" or "Group
Plan ") established and maintained by Monroe
County Board of County Commissioners.
be coordinated with other policies or plans;
and the Group Health Plan's subrogation
rights and right of reimbursement.
You will need to refer to the Schedule of
Benefits to determine how much you have to
pay for particular Health Care Services.
The sponsor of your Group Health Plan has
contracted with Blue Cross Blue Shield of
Florida, Inc. ( BCBSF), under an Administrative
Services Only Agreement ( "ASO Agreement "),
to provide certain third party administrative
services, including claims processing, customer
service, and other services, and access to
certain of its Provider networks. BCBSF
provides certain administrative services only and
does not assume any financial risk or obligation
with respect to Health Care Services rendered to
Covered Persons or claims submitted for
processing under this Benefit Booklet for such
Services. The payment of claims under the
Group Health Plan depends exclusively upon
the funding provided by Monroe County BOCC.
You should read your Benefit Booklet carefully
before you need Health Care Services. It
contains valuable information about:
• your BlueOptions benefits;
• what is covered;
• what is excluded or not covered;
• coverage and payment rules;
• Blueprint for Health Programs;
• how and when to file a claim;
• how much, and under what circumstances,
payment will be made;
• what you will have to pay as your share; and
• other important information including when
benefits may change; how and when
coverage stops; how to continue coverage if
you are no longer eligible; how benefits will
When reading your Booklet, please
remember that:
• you should read this Booklet in its entirety in
order to determine if a particular Health Care
Service is covered.
• the headings of sections contained in this
Booklet are for reference purposes only and
shall not affect in any way the meaning or
interpretation of particular provisions.
• references to "you" or `your" throughout refer
to you as the Covered Plan Participant and to
your Covered Dependents, unless expressly
stated otherwise or unless, in the context in
which the term is used, it is clearly intended
otherwise. Any references which refer solely
to you as the Covered Plan Participant or
solely to your Covered Dependent(s) will be
noted as such.
• references to "we ", "us ", and `bur" throughout
refer to Blue Cross and Blue Shield of
Florida, Inc. We may also refer to ourselves
as "BCBSF ".
• if a word or phrase starts with a capital letter,
it is either the first word in a sentence, a
proper name, a title, or a defined term. If the
word or phrase has a special meaning, it will
either be defined in the Definitions section or
defined within the particular section where it
is used.
How to Use Your Benefit Booklet 1 -1
Where do you find information on........
• what particular types of Health Care
Services are covered?
Read the "What Is Covered ?" and "What Is
Not Covered ?" sections.
• how much will be paid under your Group
Health Plan and how much do you have to
pay?
Read the "Understanding Your Share of
Health Care Expenses" section along with the
Schedule of Benefits.
• how the amount you pay for Covered
Services under the BlueCard (Out -of-
State) Program will be determined when
you receive care outside the state of
Florida?
• how to add or remove a Dependent?
Read the "Enrollment and Effective Date of
Coverage" section.
• what happens if you are covered under
this Benefit Booklet and another health
plan?
Read the "Duplication of Coverage Under
Other Health Plans Programs" section.
• what happens when your coverage ends?
Read the "Termination of Coverage" section.
• what the terms used throughout this
Booklet mean?
Read the "Definitions" section.
Read the "BlueCard (Out -of- State) Program"
section.
Overview of How BlueOptions Works
Whenever you need care, you have a choice. If you visit an:
In- Network Provider
Out -of- Network Provider
You receive In- Network benefits, the
You receive the Out -of- Network level of
highest level of coverage available.
benefits — you will share more of the cost of
your care.
You do not have to file a claim; the claim
You may be required to submit a claim form.
will be filed by the In- Network Provider for
you.
The In- Network Provider* is responsible
You should notify BCBSF of inpatient
for Admission Notification if you are
admissions.
admitted to the Hospital.
*For Services rendered by an In- Network Provider located outside of Florida, you should
notify us of inpatient admissions.
How to Use Your Benefit Booklet 1 -2
Section 2: What Is Covered?
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.
Exclusion:
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:
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 ( "CRNX)
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 9 th birthday
consisting of:
1. 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 Dependency 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.
Exclusion:
Long term Services for alcoholism or drug
addiction, including specialized inpatient units or
inpatient stays that are primarily intended as a
change of environment.
Breast Reconstructive Surgery
Surgery to reestablish symmetry between two
breasts and implanted prostheses incident to
What Is Covered? 2 -5
Mastectomy is covered. In order to be covered,
such surgery must be provided in a manner
chosen by your Physician, consistent with
prevailing medical standards, and in consultation
with you.
Child Cleft Lip and Cleft Palate Treatment
Treatment and Services for Child Cleft Lip and
Cleft Palate, including medical, dental, Speech
Therapy, audiology, and nutrition Services for
treatment of a child under the age of 18 who has
cleft lip or cleft palate are covered. In order for
such Services to be covered, your Covered
Dependent's Physician must specifically
prescribe such Services and such Services must
be Medically Necessary and consequent to
treatment of the cleft lip or cleft palate.
Clinical Trials
Clinical trials are research studies in which
Physicians and other researchers work to find
ways to improve care. Each study tries to
answer scientific questions and to find better
ways to prevent, diagnose, or treat patients.
Each trial has a protocol which explains the
purpose of the trial, how the trial will be
performed, who may participate in the trial, and
the beginning and end points of the trial.
If you are eligible to participate in an Approved
Clinical Trial, routine patient care for Services
furnished in connection with your participation in
the Approved Clinical Trial may be covered
when:
1. an In- Network Provider has indicated such
trial is appropriate for you; or
2. you provide us with medical and scientific
information establishing that your
participation in such trial is appropriate.
Routine patient care includes all Medically
Necessary Services that would otherwise be
covered under this Booklet, such as doctor
visits, lab tests, x -rays and scans and hospital
stays related to treatment of your Condition and
is subject to the applicable Cost Share(s) on the
Schedule of Benefits.
Even though benefits may be available under
this Booklet for routine patient care related to an
Approved Clinical Trial you may not be eligible
for inclusion in these trials or there may not be
any trials available to treat your Condition at the
time you want to be included in a clinical trial.
Exclusion:
1. Costs that are generally covered by the
clinical trial, including, but not limited to
a. Research costs related to conducting
the clinical trial such as research
Physician and nurse time, analysis of
results, and clinical tests performed only
for research purposes.
b. The investigational item, device or
Service itself.
c. Services inconsistent with widely
accepted and established standards of
care for a particular diagnosis.
2. Services related to an Approved Clinical
Trial received outside of the United States.
Concurrent Physician Care
Concurrent Physician care Services are
covered, provided: (a) the additional Physician
actively participates in your treatment; (b) the
Condition involves more than one body system
or is so severe or complex that one Physician
cannot provide the care unassisted; and (c) the
Physicians have different specialties or have the
same specialty with different sub - specialties.
Consultations
Consultations provided by a Physician are
covered if your attending Physician requests the
consultation and the consulting Physician
prepares a written report.
Contraceptive Injections
What Is Covered? 2 -6
Medication by injection is covered when
provided and administered by a Physician, for
the purpose of contraception, and is limited to
the medication and administration when
Medically Necessary.
1. Dental Services provided more than 90 days
after the date of an Accidental Dental Injury
regardless of whether or not such services
could have been rendered within 90 days;
and
Dental Services
2. Dental Implant.
Dental Services are limited to the following:
Diabetes Outpatient Self- Management
1. Care and stabilization treatment rendered
Diabetes outpatient self- management training
within 90 days of an Accidental Dental Injury
and educational Services and nutrition
to Sound Natural Teeth.
counseling (including all Medically Necessary
2. Extraction of teeth required prior to radiation
equipment and supplies) to treat diabetes, if
therapy when you have a diagnosis of
your treating Physician or a Physician who
cancer of the head and /or neck.
specializes in the treatment of diabetes certifies
3. Anesthesia Services for dental care
that such Services are Medically Necessary, are
including general anesthesia and
covered. In order to be covered, diabetes
hospitalization Services necessary to assure
outpatient self- management training and
the safe delivery of necessary dental care
educational Services must be provided under
provided to you or your Covered Dependent
the direct supervision of a certified Diabetes
in a Hospital or Ambulatory Surgical Center
Educator or a board - certified Physician
if:
specializing in endocrinology. Additionally, in
order to be covered, nutrition counseling must
a) the Covered Dependent is under 8
be provided by a licensed Dietitian. Covered
years of age and it is determined by a
Services may also include the trimming of
dentist and the Covered Dependent's
toenails, corns, calluses, and therapeutic shoes
Physician that:
(including inserts and /or modifications) for the
L dental treatment is necessary due to
treatment of severe diabetic foot disease.
a dental Condition that is
Diagnostic Services
significantly complex; or
Diagnostic Services when ordered by a
ii. the Covered Dependent has a
Physician are limited to the following:
developmental disability in which
patient management in the dental
1. radiology, ultrasound and nuclear medicine,
office has proven to be ineffective;
Magnetic Resonance Imaging (MRI);
or
2. laboratory and pathology Services;
b) you or your Covered Dependent has
3. Services involving bones or joints of the jaw
one or more medical Conditions that
(e.g., Services to treat temporomandibular
would create significant or undue
joint [TMJ] dysfunction) or facial region if,
medical risk for you in the course of
under accepted medical standards, such
delivery of any necessary dental
diagnostic Services are necessary to treat
treatment or surgery if not rendered in a
Conditions caused by congenital or
Hospital or Ambulatory Surgical Center.
developmental deformity, disease, or injury;
Exclusion:
4. approved machine testing (e.g.,
electrocardiogram [EKG],
electroencephalograph [EEG], and other
What Is Covered? 2 -7
electronic diagnostic medical procedures);
and
5. genetic testing for the purposes of
explaining current signs and symptoms of a
possible hereditary disease.
Dialysis Services
Dialysis Services including equipment, training,
and medical supplies, when provided at any
location by a Provider licensed to perform
dialysis including a Dialysis Center are covered
Down Syndrome
Down syndrome Services provided to a Covered
Dependent who is under the age of 18, or if 18
years of age or older is attending high school,
consisting of:
1. Applied Behavior Analysis, when rendered
by an individual certified per Section 393.17
of the Florida Statutes; and
2. Physical Therapy by a Physical Therapist,
Occupational Therapy by an Occupational
Therapist, and Speech Therapy by a
Speech Therapist. Covered therapies
provided in the treatment of Down syndrome
are covered even though they may be
habilitative in nature (provided to teach a
function) and are not necessarily limited to
restoration of a function or skill that has
been lost.
Payment Guidelines for Down Syndrome
Applied Behavior Analysis Services for Down
syndrome must be authorized in accordance
with criteria established by us, before such
Services are rendered. Services performed
without authorization will be denied.
Authorization for coverage is not required for
Emergency Services provided for the treatment
of an Emergency Medical Condition.
Note: In order to determine whether such
Services are covered under this Booklet, we
reserve the right to request a formal written
treatment plan signed by the treating Physician
to include the diagnosis, the proposed treatment
type, the frequency and duration of treatment,
the anticipated outcomes stated as goals, and
the frequency with which the treatment plan will
be updated, but no less than every 6 months.
Durable Medical Equipment
Durable Medical Equipment when provided by a
Durable Medical Equipment Provider and when
prescribed by a Physician, limited to the most
cost - effective equipment as determined by
BCBSF or Monroe County BOCC is covered.
Payment Guidelines for Durable Medical
Equipment
Supplies and service to repair medical
equipment may be Covered Services only if you
own the equipment or you are purchasing the
equipment. Payment for Durable Medical
Equipment will be based on the lowest of the
following: 1) the purchase price; 2) the
lease /purchase price; 3) the rental rate; or 4) the
Allowed Amount. The Allowed Amount for such
rental equipment will not exceed the total
purchase price. Durable Medical Equipment
includes, but is not limited to, the following:
wheelchairs, crutches, canes, walkers, hospital
beds, and oxygen equipment.
Note: Repair or replacement of Durable
Medical Equipment due to growth of a child or
significant change in functional status is a
Covered Service.
Exclusion:
Equipment which is primarily for convenience
and /or comfort; modifications to motor vehicles
and /or homes, including but not limited to,
wheelchair lifts or ramps; water therapy devices
such as Jacuzzis, hot tubs, swimming pools or
whirlpools; exercise and massage equipment,
electric scooters, hearing aids, air conditioners
and purifiers, humidifiers, water softeners and /or
purifiers, pillows, mattresses or waterbeds,
escalators, elevators, stair glides, emergency
alert equipment, handrails and grab bars, heat
What Is Covered? 2 -8
appliances, dehumidifiers, and the replacement
of Durable Medical Equipment solely because it
is old or used are excluded.
Emergency Services
Emergency Services for an Emergency Medical
Condition are covered when rendered In-
Network and Out -of- Network without the need
for any prior authorization determination by us.
When Emergency Services and care for an
Emergency Medical Condition are rendered by
an Out -of- Network Provider, any Copayment
and /or Coinsurance amount applicable to In-
Network Providers for Emergency Services will
also apply to such Out -of- Network Provider.
Special Payment Rules for Non - Grandfathered
Plans
The Patient Protection and Affordable Care Act
(PPACA) requires that non - grandfathered health
plans apply a specific method for determining
the allowed amount for Emergency Services
rendered for an Emergency Medical Condition
by Providers who do not have a contract with us.
Payment for Emergency Services rendered by
an Out -of- Network Provider that has not entered
into an agreement with BCBSF to provide
access to a discount from the billed amount of
that Provider will be the greater of:
the amount equal to the median amount
negotiated with all BCBSF In- Network
Providers for the same Services;
2. the Allowed Amount as defined in the
Booklet; or
3. what Medicare would have paid for the
Services rendered.
In no event will Out -of- Network Providers be
paid more than their charges for the Services
rendered.
Enteral Formulas
Prescription and non - prescription enteral
formulas for home use when prescribed by a
Physician as necessary to treat inherited
diseases of amino acid, organic acid,
carbohydrate or fat metabolism as well as
malabsorption originating from congenital
defects present at birth or acquired during the
neonatal period are covered.
Coverage to treat inherited diseases of amino
acid and organic acids, for you up to your 25th
birthday, shall include coverage for food
products modified to be low protein.
Eye Care
Coverage includes the following Services:
1. Physician Services, soft lenses or sclera
shells, for the treatment of aphakic patients;
2. initial glasses or contact lenses following
cataract surgery; and
3. Physician Services to treat an injury to or
disease of the eyes.
Exclusion:
Health Care Services to diagnose or treat vision
problems which are not a direct consequence of
trauma or prior ophthalmic surgery; eye
examinations; eye exercises or visual training;
eye glasses and contact lenses and their fitting
are excluded. In addition to the above, any
surgical procedure performed primarily to correct
or improve myopia or other refractive disorders
(e.g., radial keratotomy, PRK and LASIK) are
excluded.
Home Health Care
The Home Health Care Services listed below
are covered when the following criteria are met:
1. you are unable to leave your home without
considerable effort and the assistance of
another person because you are: bedridden
or chairbound or because you are restricted
in ambulation whether or not you use
assistive devices; or you are significantly
limited in physical activities due to a
Condition; and
What Is Covered? 2 -9
2. the Home Health Care Services rendered
have been prescribed by a Physician by way
of a formal written treatment plan that has
been reviewed and renewed by the
prescribing Physician every 30 days. In
order to determine whether such Services
are covered under this Booklet, you may be
required to provide a copy of any written
treatment plan;
3. the Home Health Care Services are
provided directly by (or indirectly through) a
Home Health Agency; and
4. you are meeting or achieving the desired
treatment goals set forth in the treatment
plan as documented in the clinical progress
notes.
Home Health Care Services are limited to:
part-time (i.e., less than 8 hours per day and
less than a total of 40 hours in a calendar
week) or intermittent (i.e., a visit of up to, but
not exceeding, 2 hours per day) nursing
care by a Registered Nurse, Licensed
Practical Nurse and /or home health aide
Services;
2. home health aide Services must be
consistent with the plan of treatment,
ordered by a Physician, and rendered under
the supervision of a Registered Nurse;
3. medical social services;
4. nutritional guidance;
5. respiratory, or inhalation therapy (e.g.,
oxygen); and
6. Physical Therapy by a Physical Therapist,
Occupational Therapy by a Occupational
Therapist, and Speech Therapy by a
Speech Therapist.
Exclusions:
1. homemaker or domestic maid services;
2. sitter or companion services;
3. Services rendered by an employee or
operator of an adult congregate living
facility; an adult foster home; an adult day
care center, or a nursing home facility;
4. Speech Therapy provided for a diagnosis of
developmental delay;
5. Custodial Care except for any such care
covered under this subsection when
provided on a part -time or intermittent basis
(as defined above) by a home health aide;
6. food, housing, and home delivered meals;
and
7. Services rendered in a Hospital, nursing
home, or intermediate care facility.
Hospice Services
Health Care Services provided in connection
with a Hospice treatment program may be
Covered Services, provided the Hospice
treatment program is:
1. approved by your Physician; and
2. your doctor has certified to us in writing that
your life expectancy is 12 months or less.
Recertification is required every six months.
Hospital Services
Covered Hospital Services include:
1. room and board in a semi - private room
when confined as an inpatient, unless the
patient must be isolated from others for
documented clinical reasons;
2. intensive care units, including cardiac,
progressive and neonatal care;
3. use of operating and recovery rooms;
4. use of emergency rooms;
5. respiratory, pulmonary, or inhalation therapy
(e.g., oxygen);
6. drugs and medicines administered (except
for take home drugs) by the Hospital;
7. intravenous solutions;
What Is Covered? 2 -10
8. administration of, including the cost of,
whole blood or blood products except as
outlined in the Drugs exclusion of the "What
Is Not Covered ?" section);
9. dressings, including ordinary casts;
10. anesthetics and their administration;
11. transfusion supplies and equipment;
12. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG);
13. Physical, Speech, Occupational, and
Cardiac Therapies; and
14. transplants as described in the Transplant
Services subsection.
Exclusion:
Expenses for the following Hospital Services are
excluded when such Services could have been
provided without admitting you to the Hospital:
1) room and board provided during the
admission; 2) Physician visits provided while you
were an inpatient; 3) Occupational Therapy,
Speech Therapy, Physical Therapy, and Cardiac
Therapy; and 4) other Services provided while
you were an inpatient.
In addition, expenses for the following and
similar items are also excluded:
1. gowns and slippers;
2. shampoo, toothpaste, body lotions and
hygiene packets;
3. take -home drugs;
4. telephone and television;
5. guest meals or gourmet menus; and
6. admission kits.
Inpatient Rehabilitation
Inpatient Rehabilitation Services are covered
when the following criteria are met:
1. Services must be provided under the
direction of a Physician and must be
provided by a Medicare certified facility in
accordance with a comprehensive
rehabilitation program;
2. a plan of care must be developed and
managed by a coordinated multi - disciplinary
team;
3. coverage is subject to our Medical Necessity
coverage criteria then in effect;
4. the individual must be able to actively
participate in at least 2 rehabilitative
therapies and be able to tolerate at least 3
hours per day of skilled Rehabilitation
Services for at least 5 days a week and their
Condition must be likely to result in
significant improvement; and
5. the Rehabilitation Services must be required
at such intensity, frequency and duration
that further progress cannot be achieved in
a less intensive setting.
Inpatient Rehabilitation Services are subject to
the inpatient facility Copayment, if applicable,
and the benefit maximum set forth in the
Schedule of Benefits.
Exclusion:
All Substance Dependency, drug and alcohol
related diagnoses, Pain Management, and
respiratory ventilator management Services are
excluded.
Mammograms
Mammograms obtained in a medical office,
medical treatment facility or through a health
testing service that uses radiological equipment
registered with the appropriate Florida regulatory
agencies (or those of another state) for
diagnostic purposes or breast cancer screening
are Covered Services.
Benefits for mammograms may not be subject to
the Deductible, Coinsurance, or Copayment (if
What Is Covered? 2 -11
applicable). Please refer to your Schedule of
Benefits for more information.
Mastectomy Services
Breast cancer treatment including treatment for
physical complications relating to a Mastectomy
(including lymphedemas), and outpatient post-
surgical follow -up in accordance with prevailing
medical standards as determined by you and
your attending Physician are covered.
Outpatient post - surgical follow -up care for
Mastectomy Services shall be covered when
provided by a Provider in accordance with the
prevailing medical standards and at the most
medically appropriate setting. The setting may
be the Hospital, Physician's office, outpatient
center, or your home. The treating Physician,
after consultation with you, may choose the
appropriate setting.
Maternity Services
Health Care Services, including prenatal care,
delivery and postpartum care and assessment,
provided to you, by a Doctor of Medicine (M.D.),
Doctor of Osteopathy (D.O.), Hospital, Birth
Center, Midwife or Certified Nurse Midwife may
be Covered Services. Care for the mother
includes the postpartum assessment.
In order for the postpartum assessment to be
covered, such assessment must be provided at
a Hospital, an attending Physician's office, an
outpatient maternity center, or in the home by a
qualified licensed health care professional
trained in care for a mother. Coverage under
this Booklet for the postpartum assessment
includes coverage for the physical assessment
of the mother and any necessary clinical tests in
keeping with prevailing medical standards.
Under Federal law, your Group Plan generally
may not restrict benefits for any hospital length
of stay in connection with childbirth for the
mother or newborn child to less than 48 hours
following a vaginal delivery; or less than 96
hours following a cesarean section. However,
Federal law generally does not prohibit the
mother's or newborn's attending Provider, after
consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or
96 as applicable). In any case, under Federal
law, your Group Plan can only require that a
provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours (or
96 hours).
Exclusion:
Maternity Services rendered to a Covered
Person who becomes pregnant as a Gestational
Surrogate under the terms of, and in accordance
with, a Gestational Surrogacy Contract or
Arrangement are excluded. This exclusion
applies to all expenses for prenatal, intra - partal,
and post - partal Maternity /Obstetrical Care, and
Health Care Services rendered to the Covered
Person acting as a Gestational Surrogate.
For the definition of Gestational Surrogate and
Gestational Surrogacy Contract, see the
"Definitions" section of this Benefit Booklet.
Medical Pharmacy
Physician- administered Prescription Drugs
which are rendered in a Physician's office may
be subject to a separate Cost Share amount that
is in addition to the office visit Cost Share
amount. The Medical Pharmacy Cost Share
amount applies to each Prescription Drug and
does not include the administration of the
Prescription Drug.
Your plan may also include a maximum monthly
amount you will be required to pay out -of- pocket
for Medical Pharmacy, when such Services are
provided by an In- Network Provider or Specialty
Pharmacy. If your plan includes a Medical
Pharmacy out -of- pocket monthly maximum, it
will be listed on your Schedule of Benefits and
only applies after you have met your Deductible,
if applicable.
Please refer to your Schedule of Benefits for the
additional Cost Share amount and /or monthly
What Is Covered? 2 -12
maximum out -of- pocket applicable to Medical
Pharmacy for your plan.
Note: For purposes of this benefit, allergy
injections and immunizations are not considered
Medical Pharmacy.
Newborn Care
A newborn child will be covered from the
moment of birth provided that the newborn child
is eligible for coverage and properly enrolled.
Covered Services shall consist of coverage for
injury or sickness, including the necessary care
or treatment of medically diagnosed congenital
defects, birth abnormalities, and premature birth.
Newborn Assessment
An assessment of the newborn child is covered
provided the Services were rendered at a
Hospital, the attending Physician's office, a Birth
Center, or in the home by a Physician, Midwife
or Certified Nurse Midwife, and the performance
of any necessary clinical tests and
immunizations are within prevailing medical
standards. These Services are not subject to
the Deductible.
Ambulance Services, when necessary to
transport the newborn child to and from the
nearest appropriate facility which is staffed and
equipped to treat the newborn child's Condition,
as determined by BCBSF or Monroe County
BOCC and certified by the attending Physician
as Medically Necessary to protect the health and
safety of the newborn child, are covered.
Under Federal law, your Group Plan generally
may not restrict benefits for any hospital length
of stay in connection with childbirth for the
mother or newborn child to less than 48 hours
following a vaginal delivery; or less than 96
hours following a cesarean section. However,
Federal law generally does not prohibit the
mother's or newborn's attending Provider, after
consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or
96 as applicable). In any case, under Federal
law, your Group Plan can only require that a
provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours (or
96 hours).
Orthotic Devices
Orthotic Devices including braces and trusses
for the leg, arm, neck and back, and special
surgical corsets are covered when prescribed by
a Physician and designed and fitted by an
Orthotist.
Benefits may be provided for necessary
replacement of an Orthotic Device which is
owned by you when due to irreparable damage,
wear, a change in your Condition, or when
necessitated due to growth of a child.
Payment for splints for the treatment of
temporomandibular joint ( "TMJ") dysfunction is
limited to payment for one splint in a six -month
period unless a more frequent replacement is
determined by BCBSF or Monroe County BOCC
to be Medically Necessary.
Exclusion:
1. Expenses for arch supports, shoe inserts
designed to effect conformational changes
in the foot or foot alignment, orthopedic
shoes, over - the - counter, custom -made or
built -up shoes, cast shoes, sneakers, ready -
made compression hose or support hose, or
similar type devices /appliances regardless
of intended use, except for therapeutic
shoes (including inserts and /or
modifications) for the treatment of severe
diabetic foot disease;
2. Expenses for orthotic appliances or devices
which straighten or re -shape the
conformation of the head or bones of the
skull or cranium through cranial banding or
molding (e.g. dynamic orthotic cranioplasty
or molding helmets), except when the
orthotic appliance or device is used as an
What Is Covered? 2 -13
alternative to an internal fixation device as a
result of surgery for craniosynostosis; and
3. Expenses for devices necessary to exercise,
train, or participate in sports, e.g. custom-
made knee braces.
Osteoporosis Screening, Diagnosis, and
Treatment
Screening, diagnosis, and treatment of
osteoporosis for high -risk individuals is covered,
as Medically Necessary including, but not limited
to:
1. estrogen - deficient individuals who are at
clinical risk for osteoporosis;
2. individuals who have vertebral
abnormalities;
3. individuals who are receiving long -term
glucocorticoid (steroid) therapy; or
4. individuals who have primary
hyperparathyroidism; or
5. Individuals who have a family history of
osteoporosis.
Outpatient Cardiac, Occupational, Physical,
Speech, Massage Therapies and Spinal
Manipulation Services
Outpatient therapies listed below may be
Covered Services when ordered by a Physician
or other health care professional licensed to
perform such Services. The outpatient therapies
listed in this category are in addition to the
Cardiac, Occupational, Physical and Speech
Therapy benefits listed in the Home Health
Care, Hospital, and Skilled Nursing Facility
categories herein.
Cardiac Therapy Services provided under the
supervision of a Physician, or an appropriate
Provider trained for Cardiac Therapy, for the
purpose of aiding in the restoration of normal
heart function in connection with a myocardial
infarction, coronary occlusion or coronary
bypass surgery are covered.
Occupational Therapy Services provided by a
Physician or Occupational Therapist for the
purpose of aiding in the restoration of a
previously impaired function lost due to a
Condition are covered.
Speech Therapy Services of a Physician,
Speech Therapist, or licensed audiologist to aid
in the restoration of speech loss or an
impairment of speech resulting from a Condition
are covered.
Physical Therapy Services provided by a
Physician or Physical Therapist for the purpose
of aiding in the restoration of normal physical
function lost due to a Condition are covered.
Massage Therapy Massage provided by a
Physician, Massage Therapist, or Physical
Therapist when the Massage is prescribed as
being Medically Necessary by a Physician
licensed pursuant to Florida Statutes Chapter
458 (Medical Practice), Chapter 459
(Osteopathy), Chapter 460 (Chiropractic) or
Chapter 461 (Podiatry) is covered. The
Physician's prescription must specify the
number of treatments.
Payment Guidelines for Massage and
Physical Therapy
1. Payment for covered Massage Services is
limited to no more than four (4) 15- minute
Massage treatments per day, not to exceed
the Outpatient Cardiac, Occupational,
Physical, Speech, and Massage Therapies
and Spinal Manipulations benefit maximum
listed on the Schedule of Benefits.
2. Payment for a combination of covered
Massage and Physical Therapy Services
rendered on the same day is limited to no
more than four (4) 15- minute treatments per
day for combined Massage and Physical
Therapy treatment, not to exceed the
Outpatient Cardiac, Occupational, Physical,
Speech, and Massage Therapies and Spinal
What Is Covered? 2 -14
Manipulations benefit maximum listed on the
Schedule of Benefits.
3. Payment for covered Physical Therapy
Services rendered on the same day as
spinal manipulation is limited to one (1)
Physical Therapy treatment per day not to
exceed fifteen (15) minutes in length.
Spinal Manipulations: Services by Physicians
for manipulations of the spine to correct a slight
dislocation of a bone or joint that is
demonstrated by x -ray are covered.
Payment Guidelines for Spinal Manipulation
1. Payment for covered spinal manipulation is
limited to no more than 26 spinal
manipulations per Benefit Period, or the
maximum benefit listed in the Schedule of
Benefits, whichever occurs first.
2. Payment for covered Physical Therapy
Services rendered on the same day as a
spinal manipulation is limited to one (1)
Physical Therapy treatment per day, not to
exceed fifteen (15) minutes in length.
Your Schedule of Benefits sets forth the
maximum number of visits covered under this
plan for any combination of the outpatient
therapies and spinal manipulation Services
listed above. For example, even if you may
have only been administered two (2) of the
spinal manipulations for the Benefit Period, any
additional spinal manipulations for that Benefit
Period will not be covered if you have already
met the combined therapy visit maximum with
other Services.
Oxygen
Expenses for oxygen, the equipment necessary
to administer it, and the administration of oxygen
are covered.
Physician Services
Medical or surgical Health Care Services
provided by a Physician, including Services
rendered in the Physician's office, in an
outpatient facility, or electronically through a
computer via the Internet.
Payment Guidelines for Physician Services
Provided by Electronic Means through a
Computer:
Expenses for online medical Services provided
electronically through a computer by a Physician
via the Internet will be covered only if such
Services:
1. were provided to a covered individual who
was, at the time the Services were provided,
an established patient of the Physician
rendering the Services;
2. were in response to an online inquiry
received through the Internet from the
covered individual with respect to which the
Services were provided; and
3. were provided by a Physician through a
secure online healthcare communication
services vendor that, at the time the
Services were rendered, was under contract
with BCBSF.
The term "established patient," as used herein,
shall mean that the covered individual has
received professional services from the
Physician who provided the online medical
Services, or another physician of the same
specialty who belongs to the same group
practice as that Physician, within the past three
years.
Exclusion:
Expenses for online medical Services provided
electronically through a computer by a Physician
via the Internet other than through a healthcare
communication services vendor that has entered
into contract with BCBSF are excluded.
Expenses for online medical Services provided
by a health care provider that is not a Physician
and expenses for Health Care Services
rendered by telephone (except as indicated as
covered under the Preventive Health Services
What Is Covered? 2 -15
category of the WHAT IS COVERED? section)
are also excluded.
Preventive Health Services
Preventive Services are covered for both adults
and children based on prevailing medical
standards and recommendations which are
explained further below. Some examples of
preventive health Services include, but are not
limited to, periodic routine health exams, routine
gynecological exams, immunizations and related
preventive Services such as Prostate Specific
Antigen (PSA), routine mammograms and pap
smears. In order to be covered, Services shall
be provided in accordance with prevailing
medical standards consistent with:
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; and
6. 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:
a. Surgical procedures for the treatment of
Morbid Obesity including: intestinal
bypass; stomach stapling; balloon
dilation and associated care for the
surgical treatment of Morbid Obesity, if
the Covered Plan Participant has
previously undergone the same or
similar procedures in the lifetime of this
Group Health Plan. Surgical procedures
performed to revise, or correct defects
related to, a prior intestinal bypass,
stomach stapling or balloon dilation are
also excluded.
b. Reversal of a weight loss surgery,
surgical procedures to revise, correct,
and correction of defects to include
adjustment to devices implanted or any
fills not performed during the initial
surgical event.
Payment Guidelines for Surgical Procedures
1. 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
What Is Covered? 2 -18
will be based on 50 percent of the Allowed
Amount for any secondary surgical
procedure(s) performed. In addition,
Coinsurance or Copayment (if any) indicated
in your Schedule of Benefits will apply. This
guideline is applicable to all bilateral
procedures and all surgical procedures
performed on the same date of service.
2. Payment for incidental surgical procedures
is limited to the Allowed Amount for the
primary procedure, and there is no
additional payment for any incidental
procedure. An "incidental surgical
procedure" includes surgery where one, or
more than one, surgical procedure is
performed through the same incision or
operative approach as the primary surgical
procedure which, in BCBSF's or Monroe
County BOCC's opinion, is not clearly
identified and /or does not add significant
time or complexity to the surgical session.
For example, the removal of a normal
appendix performed in conjunction with a
Medically Necessary hysterectomy is an
incidental surgical procedure (i.e., there is
no payment for the removal of the normal
appendix in the example).
3. Payment for surgical procedures for fracture
care, dislocation treatment, debridement,
wound repair, unna boot, and other related
Health Care Services, is included in the
Allowed Amount of the surgical procedure.
Transplant Services
Transplant Services, limited to the procedures
listed below, may be covered when performed at
a facility acceptable to BCBSF or Monroe
County BOCC, subject to the conditions and
limitations described below.
Transplant includes pre - transplant, transplant
and post- discharge Services, and treatment of
complications after transplantation. Benefits will
only be paid for Services, care and treatment
received or provided in connection with a:
1. Bone Marrow Transplant, as defined herein,
which is specifically listed in the rule 596-
12.001 of the Florida Administrative Code or
any successor or similar rule or covered by
Medicare as described in the most recently
published Medicare Coverage Issues
Manual issued by the Centers for Medicare
and Medicaid Services. Coverage will be
provided for the expenses incurred for the
donation of bone marrow by a donor to the
same extent such expenses would be
covered for you and will be subject to the
same limitations and exclusions as would be
applicable to you. Coverage for the
reasonable expenses of searching for the
donor will be limited to a search among
immediate family members and donors
identified through the National Bone Marrow
Donor Program;
2. corneal transplant;
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.
What Is Covered? 2 -19
Exclusions:
Expenses for the following are excluded:
1. transplant procedures not included in the list
above, or otherwise excluded under this
Booklet (e.g., Experimental or Investigational
transplant procedures);
2. transplant procedures involving the
transplantation or implantation of any non-
human organ or tissue;
3. transplant procedures related to the donation
or acquisition of an organ or tissue for a
recipient who is not covered under this
Benefit Booklet;
4. transplant procedures involving the implant of
an artificial organ, including the implant of the
artificial organ;
5. any organ, tissue, marrow, or stem cells
which is /are sold rather than donated;
6. any Bone Marrow Transplant, as defined
herein, which is not specifically listed in rule
59B- 12.001 of the Florida Administrative
Code or any successor or similar rule or
covered by Medicare pursuant to a national
coverage decision made by the Centers for
Medicare and Medicaid Services as
evidenced in the most recently published
Medicare Coverage Issues Manual;
7. any Service in connection with the
identification of a donor from a local, state or
national listing, except in the case of a Bone
Marrow Transplant;
8. any non - medical costs, including but not
limited to, temporary lodging or transportation
costs for you and /or your family to and from
the approved facility; and
9. any artificial heart or mechanical device that
replaces either the atrium and /or the
ventricle.
What Is Covered? 2 -20
Section 3: What Is Not Covered?
Introduction
Your Booklet expressly excludes expenses for
the following Health Care Services, supplies,
drugs or charges. The following exclusions are
in addition to any exclusions specified in the
"What Is Covered ?" section or any other section
of the Booklet.
Abortions which are elective.
Arch Supports, shoe inserts designed to effect
conformational changes in the foot or foot
alignment, orthopedic shoes, over - the - counter,
custom -made or built -up shoes, cast shoes,
sneakers, ready -made compression hose or
support hose, or similar type devices /appliances
regardless of intended use, except for
therapeutic shoes (including inserts and /or
modifications) for the treatment of severe
diabetic foot disease.
clinical ecology; chelation therapy;
thermography; mind -body interactions such as
meditation, imagery, yoga, dance, and art
therapy; biofeedback; prayer and mental
healing; manual healing methods such as the
Alexander technique, aromatherapy, Ayurvedic
massage, craniosacral balancing, Feldenkrais
method, Hellerwork, polarity therapy, Reichian
therapy, reflexology, rolfing, shiatsu, traditional
Chinese massage, Trager therapy, trigger -point
myotherapy, and biofield therapeutics; Reiki,
SHEN therapy, and therapeutic touch;
bioelectromagnetic applications in medicine; and
herbal therapies.
Complications of Non - Covered Services,
including the diagnosis or treatment of any
Condition which is a complication of a non -
covered Health Care Service (e.g., Health Care
Services to treat a complication of cosmetic
surgery are not covered).
Assisted Reproductive Therapy (Infertility)
including, but not limited to, associated Services,
supplies, and medications for In Vitro
Fertilization (IVF); Gamete Intrafallopian
Transfer (GIFT) procedures; Zygote
Intrafallopian Transfer (ZIFT) procedures;
Artificial Insemination (AI); embryo transport;
surrogate parenting; donor semen and related
costs including collection and preparation; and
infertility treatment medication.
Autopsy or postmortem examination services,
unless specifically requested by BCBSF or
Monroe County BOCC.
Complementary or Alternative Medicine
including, but not limited to, self -care or self -help
training; homeopathic medicine and counseling;
Ayurvedic medicine such as lifestyle
modifications and purification therapies;
traditional Oriental medicine including
acupuncture; naturopathic medicine;
environmental medicine including the field of
Contraceptive medications, devices,
appliances, or other Health Care Services when
provided for contraception, except when
indicated as covered, under the Preventive
Health Services category of the "What Is
Covered ?" section.
Cosmetic Services, including any Service to
improve the appearance or self - perception of an
individual (except as covered under the Breast
Reconstructive Surgery category), including and
without limitation: cosmetic surgery and
procedures or supplies to correct hair loss or
skin wrinkling (e.g., Minoxidil, Rogaine, Retin -A),
and hair implants /transplants,or services used to
improve the gender specific appearance of an
individual including, but not limited to reduction
thyroid chondroplasty, liposuction, rhinoplasty,
facial bone reconstruction, face lift,
blepharoplasty, voice modification surgery, hair
removal /hairplasty, breast augmentation.
What Is Not Covered? 3 -1
Costs related to telephone consultations (except
as indicated as covered under the Preventive
Health Services category of the COVERED
SERVICES section), failure to keep a scheduled
appointment, or completion of any form and /or
medical information.
Custodial Care and any service of a custodial
nature, including and without limitation: Health
Care Services primarily to assist in the activities
of daily living; rest homes; home companions or
sitters; home parents; domestic maid services;
respite care; and provision of services which are
for the sole purposes of allowing a family
member or caregiver of a Covered Person to
return to work.
Dental Care or treatment of the teeth or their
supporting structures or gums, or dental
procedures, including but not limited to:
extraction of teeth, restoration of teeth with or
without fillings, crowns or other materials,
bridges, cleaning of teeth, dental implants,
dentures, periodontal or endodontic procedures,
orthodontic treatment (e.g., braces), intraoral
prosthetic devices, palatal expansion devices,
bruxism appliances, and dental x -rays. This
exclusion also applies to Phase II treatments (as
defined by the American Dental Association) for
TMJ dysfunction. This exclusion does not apply
to an Accidental Dental Injury and the Child Cleft
Lip and Cleft Palate Treatment Services
category as described in the 'What Is Covered ?"
section.
Drugs
1. Prescribed for uses other than the Food and
Drug Administration (FDA) approved label
indications. This exclusion does not apply to
any drug that has been proven safe,
effective and accepted for the treatment of
the specific medical Condition for which the
drug has been prescribed, as evidenced by
the results of good quality controlled clinical
studies published in at least two or more
peer- reviewed full length articles in
respected national professional medical
journals. This exclusion also does not apply
to any drug prescribed for the treatment of
cancer that has been approved by the FDA
for at least one indication, provided the drug
is recognized for treatment of your particular
cancer in a Standard Reference
Compendium or recommended for treatment
of your particular cancer in Medical
Literature. Drugs prescribed for the
treatment of cancer that have not been
approved for any indication are excluded.
2. All drugs dispensed to, or purchased by, you
from a pharmacy. This exclusion does not
apply to drugs dispensed to you when:
a. you are an inpatient in a Hospital,
Ambulatory Surgical Center, Skilled
Nursing Facility, Psychiatric Facility or a
Hospice facility;
b. you are in the outpatient department of
a Hospital;
3. dispensed to your Physician for
administration to you in the Physician's
office and prior coverage authorization has
been obtained (if required); Any non -
Prescription medicines, remedies, vaccines,
biological products (except insulin),
pharmaceuticals or chemical compounds,
vitamins, mineral supplements, fluoride
products, over - the - counter drugs, products,
or health foods, except as described in the
Preventive Health Services category of the
'What Is Covered ?" section.
4. Any drug which is indicated or used for
sexual dysfunction (e.g., Cialis, Levitra,
Viagra, Caverject). The exception described
in exclusion number one above does not
apply to sexual dysfunction drugs excluded
under this paragraph.
5. Any Self- Administered Prescription Drug not
indicated as covered in the "What Is
Covered ?" section of this Benefit Booklet.
What Is Not Covered? 3 -2
6. Blood or blood products used to treat
hemophilia, except when provided to you
for:
a. emergency stabilization;
b. during a covered inpatient stay; or
c. when proximately related to a surgical
procedure.
The exceptions to the exclusion for drugs
purchased or dispensed by a pharmacy
described in subparagraph number two do
not apply to hemophilia drugs excluded
under this subparagraph.
7. Drugs, which require prior coverage
authorization when prior coverage
authorization is not obtained.
8. Specialty Drugs used to increase height or
bone growth (e.g., growth hormone) except
for Conditions of growth hormone deficiency
documented with two abnormally low
stimulation tests of less than 10 ng /ml and
one abnormally low growth hormone
dependent peptide or for Conditions of
growth hormone deficiency associated with
loss of pituitary function due to trauma,
surgery, tumors, radiation or disease, or for
state mandated use as in patients with
AIDS.
Continuation of growth hormone therapy will
not be covered except for Conditions
associated with significant growth hormone
deficiency when there is evidence of
continued responsiveness to treatment.
(See "What is Covered ?" section for
additional information.)
Experimental or Investigational Services,
except as otherwise covered under the Bone
Marrow Transplant provision of the Transplant
Services category.
Food and Food Products prescribed or not,
except as covered in the Enteral Formulas
subsection of the "What Is Covered ?" section.
Foot Care which is routine, including any Health
Care Service, in the absence of disease. This
exclusion includes, but is not limited to: non-
surgical treatment of bunions; flat feet; fallen
arches; chronic foot strain; trimming of toenails
corns, or calluses.
General Exclusions include, but are not limited
to:
1. any Health Care Service received prior to
your Effective Date or after the date your
coverage terminates;
2. any Service to diagnose or treat any
Condition resulting from or in connection
with 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? 34
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 1. staying in the Hospital because
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.
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.
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:
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 individual Deductible and only up to the
health care expenses will be for Covered applicable Allowed Amount. Please see your
Services you receive. In addition to the Schedule of Benefits for more information.
information explained in this section, it is
important that you refer to your Schedule of Family Deductible
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
If your plan includes a family Deductible, after
the family Deductible has been met by your
family, neither you nor your Covered
Dependents will have any additional Deductible
responsibility for the remainder of that Benefit
Period. The maximum amount that any one
Covered Person in your family can contribute
toward the family Deductible, if applicable, is the
amount applied toward the individual Deductible.
Please see your Schedule of Benefits for more
information.
Copayment Requirements
Covered Services rendered by certain Providers
or at certain locations or settings will be subject
to a Copayment requirement. This is the dollar
amount you have to pay when you receive these
Services. Please refer to your Schedule of
Benefits for the specific Covered Services which
are subject to a Copayment. Listed below is a
brief description of some of the Copayment
requirements that may apply to your plan. If the
Allowed Amount or the Provider's actual charge
for a Covered Service rendered is less than the
Copayment amount, you must pay the lesser of
the Allowed Amount or the Provider's actual
charge for the Covered Service.
Individual Deductible
This amount, when applicable, must be satisfied
by you and each of your Covered Dependents
each Benefit Period, before any payment will be
made by the Group Health Plan. Only those
charges indicated on claims received for
Covered Services will be credited toward the
1. Office Services Copayment:
If your plan is a Copayment plan, the
Copayment for Covered Services rendered
in the office (when applicable) must be
satisfied by you, for each office Service
before any payment will be made. The
office Services Copayment applies
regardless of the reason for the office visit
Understanding Your Share of Health Care Expenses 5-1
and applies to all Covered Services
rendered in the office, with the exception of
Durable Medical Equipment, Medical
Pharmacy, Prosthetics, and Orthotics.
Generally, if more than one Covered Service
that is subject to a Copayment is rendered
during the same office visit, you will be
responsible for a single Copayment which
will not exceed the highest Copayment
specified in the Schedule of Benefits for the
particular Health Care Services rendered.
2. Inpatient Facility Copayment:
The inpatient facility Copayment must be
satisfied by you, for each inpatient
admission to a Hospital, Psychiatric Facility,
or Substance Abuse Facility, before any
payment will be made for any claim for
inpatient Covered Services. The inpatient
facility Copayment applies regardless of the
reason for the admission, and applies to all
inpatient admissions to a Hospital,
Psychiatric Facility or Substance Abuse
Facility in or outside the state of Florida.
Additionally, you will be responsible for out -
of- pocket expenses for Covered Services
provided by Physicians and other health
care professionals for inpatient admissions.
Note: Inpatient facility Copayments vary
depending on the facility chosen. (Please
see the Schedule of Benefits for more
information).
3. Outpatient Facility Copayment:
The outpatient facility Copayment may be
satisfied by you, for each outpatient visit to a
Hospital, Ambulatory Surgical Center,
Independent Diagnostic Testing Facility,
Psychiatric Facility or Substance Abuse
Facility, before any payment will be made for
any claim for outpatient Covered Services.
The Outpatient Facility Copayment applies
regardless of the reason for the visit, and
applies to all outpatient visits to a Hospital,
Psychiatric Facility or Substance Abuse
Facility in or outside the state of Florida.
Additionally, you will be responsible for out -
of- pocket expenses for Covered Services
provided by Physician and other healthcare
professionals.
Note: Outpatient facility Copayments vary
depending on the facility chosen. (Please
see the Schedule of Benefits for more
information).
Hospital Per Admission Deductible
The Hospital Per Admission Deductible (PAD)
must be satisfied by each Covered Plan
Participant, for each Hospital admission, before
any payment will be made for any claim for
inpatient Health Care Services. The Hospital
Per Admission Deductible applies regardless of
the reason for the admission, is in addition to the
Deductible requirement, and applies to all
Hospital admissions in or outside the state of
Florida.
Emergency Room Per Visit
Deductible
The Emergency Room Per Visit Deductible
(PVD) is set forth in the Schedule of Benefits.
The Emergency Room Per Visit Deductible
applies regardless of the reason for the visit, is
in addition to the Deductible, and applies to
emergency room services in or outside the state
of Florida. The Emergency Room Per Visit
Deductible must be satisfied by each Covered
Plan Participant for each visit. If the Covered
Plan Participant is admitted to the Hospital at the
time of the emergency room visit, the
Emergency Room Per Visit Deductible will be
waived.
Coinsurance Requirements
All applicable Deductible or Copayment amounts
must be satisfied before any portion of the
Allowed Amount will be paid for Covered
Services. For Services that are subject to
Coinsurance, the Coinsurance percentage of the
Understanding Your Share of Health Care Expenses 5-2
applicable Allowed Amount you are responsible
for is listed in the Schedule of Benefits.
Out -of- Pocket Maximums
Individual out -of- pocket maximum
Once you have reached the individual out -of-
pocket maximum amount listed in the Schedule
of Benefits, you will have no additional out -of-
pocket responsibility for the remainder of that
Benefit Period and we will pay 100 percent of
the Allowed Amount for Covered Services
rendered during the remainder of that Benefit
Period.
Family out -of- pocket maximum
If your plan includes a family out -of- pocket
maximum, once your family has reached the
family out -of- pocket maximum amount listed in
the Schedule of Benefits, neither you nor your
covered family members will have any additional
out -of- pocket responsibility for the remainder of
that Benefit Period and we will pay 100 percent
of the Allowed Amount for Covered Services
rendered during the remainder of that Benefit
Period. The maximum amount any one Covered
Person in your family can contribute toward the
family out -of- pocket maximum, if applicable, is
the amount applied toward the individual out -of-
pocket maximum. Please see your Schedule of
Benefits for more information.
Note: The Deductible, PAD, PVD, any
applicable Copayments and Coinsurance
amounts will accumulate toward the out -of-
pocket maximums. Any benefit penalty
reductions, non - covered charges or any charges
in excess of the Allowed Amount will not
accumulate toward the out -of- pocket maximums.
Prior Coverage Credit
You will be given credit for the satisfaction or
partial satisfaction of any Deductible and
Coinsurance maximums met by you under a
prior group insurance, blanket insurance, or
franchise insurance or group Health
Maintenance Organization (HMO) policy or plan
maintained by Monroe County BOCC if the
coverage provided hereunder replaces such a
policy or plan. This provision only applies if the
prior group insurance, blanket insurance,
franchise insurance, HMO or plan coverage was
in effect immediately preceding the Effective
Date of the coverage provided under this Benefit
Booklet. This provision is only applicable for you
during the initial Benefit Period of coverage
under this Benefit Booklet and the following
rules apply:
1. Prior Coverage Credit for Deductible:
For the initial Benefit Period of coverage
under this Benefit Booklet only, charges
credited towards your Deductible
requirement under the prior policy or plan,
for Services rendered during the 90 -day
period immediately preceding the Effective
Date of the coverage under this Benefit
Booklet, will be credited to the Deductible
requirement under this Booklet.
2. Prior Coverage Credit for Coinsurance:
Charges credited by Monroe County
BOCC's prior policy or plan, towards your
Coinsurance Maximum, for Services
rendered during the 90 -day period
immediately preceding the Effective Date of
coverage under this Benefit Booklet, will be
credited to your out -of- pocket maximum
under this Booklet.
3. Prior coverage credit towards the Deductible
or out -of- pocket maximums will only be
given for Health Care Services which would
have been Covered Services under this
Booklet.
4. Prior coverage credit under this Booklet only
applies at the initial enrollment of the entire
Group. You and /or Monroe County BOCC
are responsible for providing BCBSF with
any information necessary for BCBSF to
apply this prior coverage credit.
Understanding Your Share of Health Care Expenses 5-3
Benefit Maximum Carryover
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
based on the Allowed Amount for the Covered
Services provided.
Understanding Your Share of Health Care Expenses 5-4
Section 6: Physicians, Hospitals and Other Provider
Options
Introduction
It is important for you to understand how the
Provider you select and the setting in which you
receive Health Care Services affects how much
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
encouraged to select and develop a relationship
with an In- Network Family Physician. There are
several advantages to selecting a Family
Physician. Family Physicians are trained to
provide a broad range of medical care and can
be a valuable resource to coordinate your
overall healthcare needs. Developing and
continuing a relationship with a Family Physician
allows the physician to become knowledgeable
about you and your family's health history. A
Family Physician can help you determine when
you need to visit a specialist and also help you
find one based on their knowledge of you and
your specific healthcare needs. Types of Family
Physicians are Family Practitioners, General
Practitioners, Internal Medicine doctors and
Pediatricians. Additionally, care rendered by
Family Physicians usually results in lower out -of-
pocket expenses for you. Whether you select a
Family Physician or another type of Physician to
render Health Care Services, please remember
that using In- Network Providers may result in
lower out -of- pocket expenses for you. You
should always determine whether a Provider is
In- Network or Out -of- Network prior to receiving
Services to determine the amount you are
responsible for paying out -of- pocket.
Location of Service
In addition to the participation status of the
Provider, the location or setting where you
receive Services can affect the amount you pay.
For example, the amount you are responsible for
paying out -of- pocket will vary whether you
receive Services in a Hospital, a Provider's
office, or an Ambulatory Surgical Center.
Please refer to your Schedule of Benefits for
specific information regarding your out -of- pocket
expenses for such situations. After you and
your Physician have determined the plan of
treatment most appropriate for your care, you
Physicians, Hospitals and Other Provider Options 6 -1
should refer to the 'What Is Covered ?" section
and your Schedule of Benefits to find out if the
specific Health Care Services are covered and
how much you will have to pay. You should also
consult with your Physician to determine the
most appropriate setting based on your health
care and financial needs.
To verify if a Provider is In- Network
for your plan you can:
1. If in Florida, review your current BlueOptions
Provider Directory;
2. If in Florida, access the BlueOptions
Provider directory at BCBSF's web -site at
www.floridablue.com
3. If outside of Florida, access the on -line
BlueCard Doctor and Hospital Finder at
www.floridablue.com and /or
4. Call the customer service phone number in
this Booklet or on your Identification Card to
search for PPO providers.
Please remember that changes to Provider
network participation can occur at any time.
Consequently, it is your responsibility to
determine whether a specific Provider is In-
Network at the time you receive Covered
Services.
In- Network Providers
When you use In- Network Providers, your out -
of- pocket expenses for Covered Services may
be lower. Payment will be based on the Allowed
Amount and your share of the cost will be at the
In- Network benefit level listed in the Schedule of
Benefits.
Out -of- Network Providers
When you use Out -of- Network Providers your
out -of- pocket expenses for Covered Services
will be higher. We will base our payment on the
Allowed Amount at the Coinsurance percentage
listed in the Schedule of Benefits. Further, if the
Out -of- Network Provider is a Traditional
Program Provider or a BlueCard (Out -of- State)
Traditional Program Provider, our payment to
such Provider may be under the terms of that
Provider's contract. If your Schedule of Benefits
and BlueOptions Provider directory do not
include a Provider as In- Network under your
benefit plan, the Provider is considered Out -of-
Network.
Physicians, Hospitals and Other Provider Options 6 -2
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In- Network or Out -of- Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians, Hospitals and Other Provider Options 6 -3
In- Network
Out -of- Network
What expenses
• Any applicable Copayments, Deductible(s) and /or Coinsurance requirements;
are you
• Expenses for Services which are not covered;
responsible for
• Expenses for Services in excess of any benefit maximum limitations;
paying?
• Expenses for claims denied because we did not receive information
requested from you regarding whether or not you have other coverage and
the details of such coverage; and
• Expenses for Services which are excluded.
Who is
• The Provider will file the claim
• You are responsible for filing the
responsible for
for you and payment will be
claim and payment will be made
filing your
made directly to the Provider.
directly to the Covered Plan
claims?
Participant. If you receive Services
from a Provider who participates in
our Traditional Program or is a
BlueCard (Out -of- State) Traditional
Program Provider, the Provider will
file the claim for you. In those
instances payment will be made
directly to the Provider.
Can you be billed
NO. You are protected from
• YES. You are responsible for paying
the difference
being billed for the difference in
the difference between what we pay
between what the
the Allowed Amount and the
and the Provider's charge. However,
Provider is paid
Provider's charge when you use
if you receive Services from a
and the Provider's
In- Network Providers. The
Provider who participates in our
charge?
Provider will accept the Allowed
Traditional Program, the Provider will
Amount as payment in full for
accept our Allowed Amount as
Covered Services except as
payment in full for Covered Services
otherwise permitted under the
since such Traditional Program
terms of the Provider's contract
Providers have agreed not to bill you
and this Booklet.
for the difference. Further, under the
BlueCard (Out -of- State) Program,
when you receive Covered Services
from a BlueCard (Out -of- State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In- Network or Out -of- Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians, Hospitals and Other Provider Options 6 -3
Physicians
When you receive Covered Services from a
Physician you will be responsible for a
Copayment and /or the Deductible and the
applicable Coinsurance. Several factors will
determine your out -of- pocket expenses including
your Schedule of Benefits, whether the
Physician is In- Network or Out -of- Network, the
location of service, the type of Service rendered,
and the Physician's specialty.
Remember that the location or setting where a
Service is rendered can affect the amount you
are responsible for paying out -of- pocket. After
you and your Physician have determined the
plan of treatment most appropriate for your care,
you should refer to the Schedule of Benefits and
consult with your Physician to determine the
most appropriate setting based on your health
care and financial needs.
Refer to your Schedule of Benefits to determine
the applicable Copayments, Coinsurance
percentage and /or Deductible amount you are
responsible for paying for Physician Services.
Hospitals
Each time you receive inpatient or outpatient
Covered Services at a Hospital, in addition to
any out -of- pocket expenses related to Physician
Services, you will be responsible for out -of-
pocket expenses related to Hospital Services.
In- Network Hospitals have been divided into two
groups that are referred to as "options" on the
Schedule of Benefits. The amount you are
responsible for paying out -of- pocket is different
for each of these options. Remember that there
are also different out -of- pocket expenses for
Out -of- Network Hospitals.
Since not all Physicians admit patients to every
Hospital, it is important when choosing a
Physician that you determine the Hospitals
where your Physician has admitting privileges.
You can find out what Hospitals your Physician
admits to by contacting the Physician's office.
This will provide you with information that will
help you determine a portion of what your out -of-
pocket costs may be in the event you are
hospitalized.
Refer to your Schedule of Benefits to determine
the applicable out -of- pocket expenses you are
responsible for paying for Hospital Services.
Specialty Pharmacy
Certain medications, such as injectable, oral,
inhaled and infused therapies used to treat
complex medical Conditions are typically more
difficult to maintain, administer and monitor
when compared to traditional Drugs. Specialty
Drugs may require frequent dosage
adjustments, special storage and handling and
may not be readily available at local pharmacies
or routinely stocked by Physicians' offices,
mostly due to the high cost and complex
handling they require.
Using the Specialty Pharmacy to provide these
Specialty Drugs should lower the amount you
have to pay for these medications, while helping
to preserve your benefits.
Other Providers
With BlueOptions you have access to other
Providers in addition to the ones previously
described in this section. Other Providers
include facilities that provide alternative
outpatient settings or other persons and entities
that specialize in a specific Service(s). While
these Providers may be recognized for payment,
they may not be included as In- Network
Providers for your plan. Additionally, all of the
Services that are within the scope of certain
Providers' licenses may not be Covered
Services under this Booklet. Please refer to the
'What Is Covered ?" and 'What Is Not Covered ?"
sections of this Booklet and your Schedule of
Benefits to determine your out -of- pocket
Physicians, Hospitals and Other Provider Options 6 -4
expenses for Covered Services rendered by
these Providers.
You may be able to receive certain outpatient
Services at a location other than a Hospital. The
amount you are responsible for paying for
Services rendered at some alternative facilities
is generally less than if you had received those
same Services at a Hospital.
Remember that the location of service can
impact the amount you are responsible for
paying out -of- pocket. After you and your
Physician have determined the plan of treatment
most appropriate for your care, you should refer
to the Schedule of Benefits and consult with
your Physician to determine the most
appropriate setting based on your health care
and financial needs. When Services are
rendered at an outpatient facility other than a
Hospital there may be an out -of- pocket expense
for the facility Provider as well as an out -of-
pocket expense for other types of Providers.
Assignment of Benefits to Providers
Except as set forth in the last paragraph of this
section, any of the following assignments, or
attempted assignments, by you to any Provider
will not be honored:
• an assignment of the benefits due to you for
Covered Services under this Benefit
Booklet;
• an assignment of your right to receive
payments for Covered Services under this
Benefit Booklet; or
• an assignment of a claim for damage
resulting from a breach, or an alleged
breach of the terms of this Benefit Booklet.
We specifically reserve the right to honor an
assignment of benefits or payment by you to a
Provider who: 1) is In- Network under your plan
of coverage; 2) is a NetworkBlue Provider even
if that Provider is not in the panel for your plan of
coverage; 3) is a Traditional Program Provider;
4) is a BlueCard (Out -of- State) PPO Program
Provider; 5) is a BlueCard (Out -of- State)
Traditional Program Provider; 6) is a licensed
Hospital, Physician, or dentist and the benefits
which have been assigned are for care provided
pursuant to section 395.1041, Florida Statutes;
or 7) is an Ambulance Provider that provides
transportation for Services from the location
where an "Emergency Medical Condition ",
defined in section 395.002(8) Florida Statutes,
first occurred to a Hospital, and the benefits
which have been assigned are for transportation
to care provided pursuant to section 395.1041,
Florida Statutes. A written attestation of the
assignment of benefits may be required.
Physicians, Hospitals and Other Provider Options 6 -5
Section 7: BlueCard (Out -of- State) Program
Out -of -Area Services
Overview
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
obligations to you. However, the Host Blue is
responsible for contracting with and generally
handling all interactions with its Participating
Providers.
When you receive Covered Services outside of
Florida and the claim is processed through the
BlueCard Program, the amount you pay for
Covered Services is calculated based on the
lower of:
• The billed charges for Covered Services; or
The negotiated price that the Host Blue
makes available to us.
Often, this "negotiated price" will be a simple
discount that reflects an actual price that the Host
Blue pays to your Provider. Sometimes, it is an
estimated price that takes into account special
arrangements with your Provider or Provider
group that may include types of settlements,
incentive payments and /or other credits or
charges. Occasionally, it may be an average
price, based on a discount that results in
expected average savings for similar types of
Providers after taking into account the same
types of transactions as with an estimated price.
Estimated pricing and average pricing also take
into account adjustments to correct for over- or
underestimation of past pricing of claims, as
noted above. However, such adjustments will not
affect the price we have used for your claim
because they will not be applied after a claim has
already been paid.
Special Cases: Value -Based Programs
If you receive Covered Services under a Value -
Based Program inside a Host Blue's service area,
you will not be responsible for paying any of the
Provider Incentives, risk - sharing, and /or Care
Coordinator Fees that are a part of such an
arrangement, except when a Host Blue passes
BlueCard (Out -of- State) Program 7 -1
these fees to us through average pricing or fee
schedule adjustments. Additional information is
available upon request.
Inter -Plan Programs: Federal /State
Taxes /Surcharges /Fees
Federal or state laws or regulations may
require a surcharge, tax or other fee that
applies to self- funded accounts. If applicable,
we will include any such surcharge, tax or other
fee as part of the claim charge passed on to
you.
Nonparticipating Providers Outside Florida
When Covered Services are provided outside
of Florida by Nonparticipating Providers,
payment will be based on the Allowed Amount,
as defined in the DEFINITIONS section of the
Benefit Booklet.
BlueCard Worldwide Program
If you are outside the United States, the
Commonwealth of Puerto Rico, and the U.S.
Virgin Islands (hereinafter `BlueCard Service
Area "), you may be able to take advantage of
the BlueCard Worldwide Program when
accessing Covered Services. The BlueCard
Worldwide Program is unlike the BlueCard
Program available in the BlueCard Service
Area in certain ways. For instance, although
the BlueCard Worldwide Program assists you
with accessing a network of inpatient,
outpatient and professional Providers, the
network is not served by a Host Blue. As such,
when you receive care from Providers outside
the BlueCard Service Area, you will typically
have to pay the Providers and submit the
claims yourself to obtain reimbursement for
these Services.
If you need medical assistance services
(including locating a doctor or hospital) outside
the BlueCard Service Area, you should call the
BlueCard Worldwide Service Center at
1.800.810.BLUE (2583) or call collect at 804-
673 -1177, 24 hours a day, seven days a week.
An assistance coordinator, working with a
medical professional, can arrange a physician
appointment or hospitalization, if necessary.
Inpatient Services
In most cases, if you contact the BlueCard
Worldwide Service Center for assistance,
hospitals will not require you to pay for inpatient
Covered Services, except for your Cost Share
amounts. In such cases, the hospital will submit
your claims to the BlueCard Worldwide Service
Center to begin claims processing. However, if
you paid in full at the time of Service, you must
submit a claim to receive reimbursement for
Covered Services. You must notify us of any
non - emergency inpatient Services.
Outpatient Services
Physicians, Urgent Care Centers and other
outpatient Providers located outside the BlueCard
Service Area will typically require you to pay in
full at the time of Service. You must submit a
claim to obtain reimbursement for Covered
Services.
Submitting a BlueCard Worldwide Claim
When you pay for Covered Services outside the
BlueCard Service Area, you must submit a claim
to obtain reimbursement. For institutional and
professional claims, you should complete a
BlueCard Worldwide International claim form and
send the claim form with the Provider's itemized
bill(s) to the BlueCard Worldwide Service Center
(the address is on the form) to initiate claims
processing. Following the instructions on the
claim form will help ensure timely processing of
your claim. The claim form is available from the
BlueCard Worldwide Service Center or online at
www.bluecardworldwide.com If you need
assistance with your claim submission, you
should call the BlueCard Worldwide Service
Center at 800 - 810 -BLUE (2583) or call collect at
804 - 673 -1177, 24 hours a day, seven days a
week..
BlueCard (Out -of- State) Program 7 -2
Section 8: Blueprint for Health Programs
Introduction
BCBSF has established (and from time to time
establishes) various customer - focused health
education and information programs as well as
benefit utilization management and utilization
review programs. Under the terms of the ASO
Agreement between BCBSF and Monroe
County BOCC, BCBSF has agreed to make
these programs available to you. These
programs, collectively called the Blueprint for
Health Programs, are designed to 1) provide you
with information that will help you make more
informed decisions about your health, 2) help
facilitate the management and review of
coverage and benefits provided under this
Booklet and 3) present opportunities, as
explained below, to mutually agree upon
alternative benefits or payment alternatives for
cost - effective medically appropriate Health Care
Services. Some BluePrint For Health
Programs may not be available outside the
state of Florida.
Admission Notification
The admission notification requirements vary
depending on whether you are admitted to a
Hospital, Psychiatric Facility, Substance Abuse
Facility or Skilled Nursing Facility which is In-
Network or Out -of- Network.
Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility (as applicable) if we
have been notified of your admission. For an
admission outside of Florida, you or the
Hospital, Psychiatric Facility, Substance Abuse
Facility or Skilled Nursing Facility (as applicable)
should notify us of the admission. Making sure
that we are notified of your admission will enable
us to provide you information about the Blueprint
for Health Programs available to you. You or
the Hospital, Psychiatric Facility, Substance
Abuse Facility or Skilled Nursing Facility (as
applicable) may notify us of your admission by
calling the toll free customer service number on
your ID card.
Out -of- Network
For admissions to an Out -of- Network Hospital,
Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility, you or the Hospital,
Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility should notify BCBSF of
the admission. Notifying BCBSF of your
admission will enable BCBSF to provide you
information about the Blueprint for Health
Programs available to you. You or the Hospital
may notify BCBSF of your admission by calling
the toll -free customer service number on your ID
card.
In- Network
Under the admission notification requirement,
we must be notified of all inpatient admissions
(i.e., elective, planned, urgent or emergency) to
In- Network Hospitals, Psychiatric Facilities,
Substance Abuse Facilities or Skilled Nursing
Facilities. While it is the sole responsibility of
the In- Network Provider located in Florida to
comply with our admission notification
requirements, you should ask the Hospital,
Inpatient Facility Program
Under the inpatient facility program, we may
review Hospital stays, Hospice, Inpatient
Rehabilitation, LTAC and Skilled Nursing Facility
(SNF) Services, and other Health Care Services
rendered during the course of an inpatient stay
or treatment program. We may conduct this
review while you are inpatient, after your
discharge, or as part of a review of an episode
of care when you are transferred from one level
Blueprint for Health Programs 8 -1
of inpatient care to another for ongoing
treatment. The review is conducted solely to
determine whether we should provide coverage
and /or payment for a particular admission or
Health Care Services rendered during that
admission. Using our established criteria then in
effect, a concurrent review of the inpatient stay
may occur at regular intervals, including in
advance of a transfer from one inpatient facility
to another. We will provide notification to your
Physician when inpatient coverage criteria are
no longer met. In administering the inpatient
facility program, we may review specific medical
facts or information and assess, among other
things, the appropriateness of the Services
being rendered, health care setting and /or the
level of care of an inpatient admission or other
health care treatment program. Any such
reviews by us, and any reviews or assessments
of specific medical facts or information which we
conduct, are solely for purposes of making
coverage or payment decisions under this
Benefit Booklet and not for the purpose of
recommending or providing medical care.
Provider Focused Utilization
Management Program
Certain NetworkBlue Providers have agreed to
participate in our focused utilization
management program. This pre - service review
program is intended to promote the efficient
delivery of medically appropriate Health Care
Services by NetworkBlue Providers. Under this
program we may perform focused prospective
reviews of all or specific Health Care Services
proposed for you. In order to perform the
review, we may require the Provider to submit to
us specific medical information relating to Health
Care Services proposed for you. These
NetworkBlue Providers have agreed not to bill,
or collect, any payment whatsoever from you or
us, or any other person or entity, with respect to
a specific Health Care Service if:
1. they fail to submit the Health Care Service
for a focused prospective review when
required under the terms of their agreement
with us; or
2. we perform a focused review under the
focused utilization management program
and we determine that a Health Care
Service is not Medically Necessary in
accordance with our Medical Necessity
criteria or inconsistent with our benefit
guidelines then in effect unless the following
exception applies.
Exception for Certain NetworkBlue Physicians
Certain NetworkBlue Physicians licensed as
Doctors of Medicine (M.D.) or Doctors of
Osteopathy (D.O.) only may bill you for Services
determined to be not Medically Necessary by
BCBSF under this focused utilization
management program if, before you receive the
Service:
a. they give you a written estimate of your
financial obligation for the Service;
b. they specifically identify the proposed
Service that BCBSF has determined not to
be Medically Necessary; and
c. you agree to assume financial responsibility
for such Service.
Prior Coverage Authorization/Pre-
Service Notification Programs
It is important for you to understand our prior
coverage authorization programs and how the
Provider you select and the type of Service you
receive affects these requirements and
ultimately how much you are responsible for
paying under this Benefit Booklet.
You or your Provider will be required to obtain
prior coverage authorization from us for:
1. advanced diagnostic imaging Services,
such as CT scans, MRIs, MRA and nuclear
imaging;
2. Autism Spectrum Disorder; and
Blueprint for Health Programs 8 -2
3. other Health Care Services that are or may
become subject to a prior coverage
authorization program or a pre - service
notification program as defined and
administered by us.
Prior coverage authorization requirements vary,
depending on whether Services are rendered by
an In- Network Provider or an Out -of- Network
Provider, as described below:
In- Network Providers
It is the In- Network Provider's sole responsibility
to comply with our prior coverage authorization
requirements, and therefore you will not be
responsible for any benefit reductions if prior
coverage authorization is not obtained before
Medically Necessary Services are rendered.
Once we have received the necessary medical
documentation from the Provider, we will review
the information and make a prior coverage
authorization decision, based on our established
criteria then in effect. The Provider will be
notified of the prior coverage authorization
decision.
Out -of- Network Providers
In the case of advanced diagnostic
imaging Services such as CT scans, MRIs,
MRA and nuclear imaging, it is your sole
responsibility to comply with our prior
coverage authorization requirements when
rendered or referred by an Out -of- Network
Provider before the advanced diagnostic
imaging Services are provided. Your
failure to obtain prior coverage
authorization will result in denial of
coverage for such Services.
For additional details on how to obtain prior
coverage authorization for advanced
diagnostic imaging Services, please call the
customer service phone number on the back
of your ID Card.
2. In the case of Autism Spectrum Disorder,
under a prior coverage authorization or pre -
service notification program, it is your sole
responsibility to comply with our prior
coverage authorization or pre - service
notification requirements when rendered or
referred by an Out -of- Network Provider,
before the Services are provided. Failure
to obtain prior coverage authorization
will result in denial of coverage for such
Services.
3. In the case of other Health Care Services
under a prior coverage authorization or pre -
service notification program, it is your sole
responsibility to comply with our prior
coverage authorization or pre - service
notification requirements when rendered or
referred by an Out -of- Network Provider,
before the Services are provided. Failure
to obtain prior coverage authorization or
provide pre - service notification may
result in denial of the claim or application
of a financial penalty assessed at the
time the claim is presented for payment
to us. The penalty applied will be the lesser
of $500 or 20% of the total Allowed Amount
of the claim. The decision to apply a penalty
or deny the claim will be made uniformly and
will be identified in the notice describing the
prior coverage authorization and pre - service
notification programs.
Once the necessary medical documentation has
been received from you and /or the Out -of-
Network Provider, BCBSF or a designated
vendor, will review the information and make a
prior coverage authorization decision, based on
our established criteria then in effect. You will
be notified of the prior coverage authorization
decision.
BCBSF will provide you information for any Out -
of- Network Health Care Service subject to a
prior coverage authorization or pre - service
notification program, including how you can
Blueprint for Health Programs 8 -3
obtain prior coverage authorization and /or
provide the pre - service notification for such
Service not already listed here. This information
will be provided to you upon enrollment, or at
least 30 days prior to such Out -of- Network
Services becoming subject to a prior coverage
authorization or pre - service notification program.
See the "Claims Processing" section for
information on what you can do if prior coverage
authorization is denied.
Note: Prior coverage authorization is not
required when Covered Services are provided
for the treatment of an Emergency Medical
Condition.
Member Focused Programs
The Blueprint for Health Programs may include
voluntary programs for certain members. These
programs may address health promotion,
prevention and early detection of disease,
chronic illness management programs, case
management programs and other member
focused programs.
Personal Case Management Program
The personal case management program
focuses on members who suffer from a
catastrophic illness or injury. In the event you
have a catastrophic or chronic Condition, we
may, in BCBSF's sole discretion, assign a
Personal Case Manager to you to help
coordinate coverage, benefits, or payment for
Health Care Services you receive. Your
participation in this program is completely
voluntary
Under the personal case management program,
you may be offered alternative benefits or
payment for cost - effective Health Care Services.
These alternative benefits or payments may be
made available on a case -by -case basis when
you meet BCBSF's case management criteria
then in effect. Such alternative benefits or
payments, if any, will be made available in
accordance with a treatment plan with which
you, or your representative, and your Physician
agree to in writing. In addition, Monroe County
BOCC will be required to specifically agree to
such treatment plan and the alternative benefits
or payment.
The fact that certain Health Care Services under
the personal case management program have
been provided or payment has been made in no
way obligates BCBSF, Monroe County BOCC,
or the Group Health Plan to continue to provide
or pay for the same or similar Services. Nothing
contained in this section shall be deemed a
waiver of Monroe County BOCC's right to
enforce this Booklet in strict accordance with its
terms. The terms of this Booklet will continue to
apply, except as specifically modified in writing
in accordance with the personal case
management program rules then in effect.
Blueprint for Health Programs 8 -4
Health Information, Promotion, Prevention
and Illness Management Programs
These Blueprint for Health Programs may
include health information that supports health
care education and choices for healthcare
issues. These programs focus on keeping you
well, help to identify early preventive measures
of treatment and help covered individuals with
chronic problems to enjoy lives that are as
productive and healthy as possible. These
programs may include prenatal educational
programs and illness management programs for
Conditions such as diabetes, cancer and heart
disease. These programs are voluntary and are
designed to enhance your ability to make
informed choices and decisions for your unique
health care needs. You may call the toll free
customer service number on your ID card for
more information. Your participation in this
program is completely voluntary
IMPORTANT INFORMATION RELATING TO
BCBSF'S BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain to
independent professional medical /clinical
judgment or training, or the need for medical
services, are solely your responsibility and the
responsibility of your Physicians and other
health care Providers. You and your Physicians
are responsible for deciding what medical care
should be rendered or received, and when and
how that care should be provided. Monroe
County BOCC is ultimately responsible for
determining whether expenses, which have
been or will be incurred for medical care are, or
will be, covered under this Booklet. In fulfilling
this responsibility, neither BCBSF nor Monroe
County BOCC will be deemed to participate in or
override the medical decisions of your health
care Provider.
Please note that the Hospital admission
notification requirement and any Blueprint For
Health Program may be discontinued or
modified at any time without notice to you or
your consent.
Blueprint for Health Programs 8 -5
Section 9: Eligibility for Coverage
Each employee or other individual who is eligible
to participate in the Monroe County BOCC
Group Health Plan, and who meets and
continues to meet the eligibility requirements
described in this Booklet, shall be entitled to
apply for coverage under this Booklet. These
eligibility requirements are binding upon you
and /or your eligible family members. No
changes in the eligibility requirements will be
permitted except as permitted by Monroe
County BOCC. Acceptable documentation may
be required as proof that an individual meets
and continues to meet the eligibility
requirements such as a court order naming the
Eligible Employee as the legal guardian or
appropriate adoption documentation described
in the "Enrollment and Effective Date of
Coverage" section.
Note: Employees and qualified Dependents are
eligible for coverage on the day following the
60 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 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.
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 XVI I I 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
26 birthday.
This eligibility shall terminate on the last day of
the month in which the dependent child no
longer meets the requirements for extended
eligibility as a handicapped child.
Exception for Students on Medical Leave of
Absence from School
A Covered Dependent child who is a full -time or
part -time student at an accredited post-
secondary institution, who takes a physician
certified medically necessary leave of absence
from school, will still be considered a student for
eligibility purposes under this Booklet for the
earlier of 12 months from the first day of the
leave of absence or the date the Covered
Dependent would otherwise no longer be eligible
for coverage under this Booklet.
Eligibility For Coverage 9 -2
Section 10: Enrollment and Effective Date of Coverage
Eligible Employees, Eligible Retiree and Eligible
Dependents may enroll for coverage according
to the provisions below.
Employee /Retiree and the employee's spouse
under a legally valid existing marriage or
Domestic Partner.
Any Eligible Employee, Eligible Retiree or
Eligible Dependent who is not properly enrolled
will not be covered under this Benefit Booklet.
Neither BCBSF nor Monroe County BOCC will
have any obligation whatsoever to any individual
who is not properly enrolled.
Any Employee, Eligible Retiree or Eligible
Dependent who is eligible for coverage under
this Booklet may apply for coverage according to
the provisions set forth below.
Enrollment Forms /Electing Coverage
To apply for coverage, you as the Eligible
Employee, Eligible Retiree must:
1. complete and submit, through Monroe
County BOCC Benefits Office, the
Enrollment Form;
2. provide any additional information needed to
determine eligibility, at the request of
BCBSF or Monroe County BOCC Benefits
Office;
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 /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.
[•111
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
any of the applicable eligibility requirements;
A Covered Plan Participant's coverage under
this Benefit Booklet will automatically terminate
at 12:01 a.m.:
5. date specified by Monroe County BOCC that
the Dependent's coverage is terminated for
cause (see the Termination of Individual
1. on the date the Group Health Plan
terminates;
2. on the date the ASO Agreement between
BCBSF and Monroe County BOCC
terminates;
3. on the last day of the first month that the
Covered Plan Participant fails to continue to
meet any of the applicable eligibility
requirements;
4. on the date specified by Monroe County
BOCC that the Covered Plan Participant's
coverage is terminated for cause (see the
Termination of an Individual Coverage for
Cause subsection); or
5. on the date specified by Monroe County
BOCC that the Covered Plan Participant's
coverage terminates.
Termination of a Covered
Dependent's Coverage
A Covered Dependent's coverage will
automatically terminate at 12:01 a.m. on the
date:
1. the Group Health Plan terminates;
2. the Covered Plan Participant's coverage
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;
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.
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
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
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:
L you are covered under any Hospital,
surgical, medical or major medical
policy or contract or under a
prepayment plan or under any other
plan or program that provides
benefits which are similar to the
benefits provided under this Booklet;
or
ii. you are eligible, whether or not
covered, under any arrangement of
coverage for individuals in a group,
whether on an insured, uninsured,
or partially insured basis, for
benefits similar to those provided
under this Booklet; or
iii. benefits similar to the benefits
provided under this Booklet are
provided for or are available to you
pursuant to or in accordance with
the requirements of any state or
federal law (e.g., COBRA,
Medicaid); and
Conversion Privilege 13 -1
b) the benefits provided under the sources
referred to in paragraph 4.a.i or the
benefits provided or available under the
source referred to in paragraph 4.a.ii.
and 4.a.iii. above, together with the
benefits provided by our converted
policy would result in over - insurance in
accordance with our over - insurance
standards, as determined by us.
Neither Monroe County BOCC nor BCBSF
has any obligation to notify you of this
conversion privilege when your coverage
terminates or at any other time. It is your
sole responsibility to exercise this
conversion privilege by submitting a BCBSF
converted policy application and the initial
premium payment to us within 63 days of the
termination of your coverage under this
Benefit Booklet. The converted policy may
be issued without evidence of insurability
and shall be effective the day following the
day your coverage under this Benefit Booklet
terminated.
Note: Our converted policies are not a
continuation of coverage under COBRA or any
other states' similar laws. Coverage and
benefits provided under a converted policy will
not be identical to the coverage and benefits
provided under this Booklet. When applying for
our converted policy, you have two options: 1) a
converted policy providing major medical
coverage meeting the requirements of
627.6675(10) Florida Statutes or 2) a converted
policy providing coverage and benefits identical
to the coverage and benefits required to be
provided under a small employer standard
health benefit plan pursuant to Section
627.6699(12) Florida Statutes. In any event, we
will not be required to issue a converted policy
unless required to do so by Florida law. We
may have other options available to you. Call
the telephone number on your Identification card
for more information.
Conversion Privilege 13 -2
Section 14: Extension of Benefits
Extension of Benefits
In the event the Group Health Plan is
terminated, coverage will not be provided under
this Benefit Booklet for any Service rendered on
or after the termination date. The extension of
benefits provisions described below only apply
when the entire Group Health Plan is
terminated. The extension of benefits described
in this section do not apply when your coverage
terminates if the Group Health Plan remains in
effect. The extension of benefits provisions are
subject to all of the other provisions, including
the limitations and exclusions.
Note: It is your sole responsibility to provide
acceptable documentation showing that you are
entitled to an extension of benefits.
In the event you are totally disabled on the
termination date of the Group Health Plan as
a result of a specific Accident or illness
incurred while you were covered under this
Booklet, as determined by us, a limited
extension of benefits will be provided under
this Benefit Booklet for the disabled
individual only. This extension of benefits is
for Covered Services necessary to treat the
disabling Condition only. This extension of
benefits will only continue as long as the
disability is continuous and uninterrupted. In
any event, this extension of benefits will
automatically terminate at the end of the 12-
month period beginning on the termination
date of the Group Health Plan.
For purposes of this section, you will be
considered "totally disabled" only if, in our
or Monroe County BOCC's opinion, you are
unable to work at any gainful job for which
you are suited by education, training, or
experience, and you require regular care
and attendance by a Physician. You are
totally disabled only if, in our or Monroe
County BOCC's opinion, you are unable to
perform those normal day -to -day activities
which you would otherwise perform and you
require regular care and attendance by a
Physician.
2. In the event you are receiving covered
dental treatment as of the termination date
of the Group Health Plan a limited extension
of such covered dental treatment will be
provided under this Benefit Booklet if:
a) a course of dental treatment or dental
procedures were recommended in
writing and commenced in accordance
with the terms specified herein while you
were covered under the Group Health
Plan;
b) the dental procedures were procedures
for other than routine examinations,
prophylaxis, x -rays, sealants, or
orthodontic services; and
c) the dental procedures were performed
within 90 days after the Group Health
Plan terminated.
This extension of benefits is for Covered
Services necessary to complete the
dental treatment only. This extension of
benefits will automatically terminate at
the end of the 90 -day period beginning
on the termination date of the Group
Health Plan or on the date you become
covered under a succeeding insurance,
health maintenance organization or self -
insured plan providing coverage or
Services for similar dental procedures.
You are not required to be totally
disabled in order to be eligible for this
extension of benefits.
Please refer to the Dental Care category of
the "What Is Covered ?" section for a
description of the dental care Services
covered under this Booklet.
Extension of Benefits 14 -1
3. In the event you are pregnant as of the
termination date of the Group Health Plan, a
limited extension of the maternity expense
benefits included in this Booklet will be
available, provided the pregnancy
commenced while the pregnant individual
was covered under the Group Health Plan,
as determined by us or Monroe County
BOCC. This extension of benefits is for
Covered Services necessary to treat the
pregnancy only. This extension of benefits
will automatically terminate on the date of
the birth of the child. You are not required to
be Totally Disabled in order to be eligible for
this extension of benefits.
Extension of Benefits 14 -2
Section 15: The Effect of Medicare Coverage /Medicare
Secondary 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
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.
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
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
County BOCC's obligations as described in
this section.
The Effect of Medicare Coverage/ Medicare Secondary Payer Provisions 15 -1
Section 16: Duplication of Coverage Under Other Health
Plans /Programs
Coordination of Benefits
Coordination of Benefits ( "COB ") is a limitation
of coverage and /or benefits to be provided under
this Benefit Booklet.
COB determines the manner in which expenses
will be paid when you are covered under more
than one health plan, program, or policy
providing benefits for Health Care Services.
COB is designed to avoid the costly duplication
of payment for Covered Services. It is your
responsibility to provide BCBSF and Monroe
County BOCC Benefits Office information
concerning any duplication of coverage under
any other health plan, program, or policy you or
your Covered Dependents may have. This
means you must notify BCBSF and Monroe
County BOCC Benefits Office in writing if you
have other applicable coverage or if there is no
other coverage. You may be requested to
provide this information at initial enrollment, by
written correspondence annually thereafter, or in
connection with a specific Health Care Service
you receive. If the information is not received,
claims may be denied and you will be
responsible for payment of any expenses related
to denied claims.
Health plans, programs or policies which may be
subject to COB include, but are not limited to,
the following which will be referred to as
"plan(s)" for purposes of this section:
with which the law permits coordination of
benefits;
4. Medicare, as described in "The Effect of
Medicare Coverage /Medicare Secondary
Payer Provisions" section; and
5. to the extent permitted by law, any other
government sponsored health insurance
program.
The amount of payment, if any, when benefits
are coordinated under this section, is based on
whether or not the benefits under this Benefit
Booklet are primary. When primary, payment
will be made for Covered Services without
regard to coverage under other plans. When the
benefits under this Benefit Booklet are not
primary, payment for Covered Services may be
reduced so that total benefits under all your
plans will not exceed 100 percent of the total
reasonable expenses actually incurred for
Covered Services. For purposes of this section,
in the event you receive Covered Services from
an In- Network Provider or an Out -of- Network
Provider who participates in the Traditional
Program, "total reasonable expenses" shall
mean the total amount required to be paid to the
Provider pursuant to the applicable agreement
BCBSF or another Blue Cross and /or Blue
Shield organization has with such Provider. In
the event that the primary payer's payment
exceeds the Allowed Amount, no payment
will be made for such Services.
1. any group or non -group health insurance,
group -type self- insurance, or HMO plan;
2. any group plan issued by any Blue Cross
and /or Blue Shield organization(s);
3. any other plan, program or insurance policy,
including an automobile PIP insurance
policy and /or medical payment coverage
The following rules shall be used to establish the
order in which benefits under the respective
plans will be determined:
1. This plan always pays secondary to any
medical payment, personal injury protection
(PIP) coverage or no -fault coverage under
any automobile policy.
Duplication of Coverage Under Other Health Plans/Programs 16 -1
2. When we cover you as a Covered
Dependent and the other plan covers you as
other than a dependent, we will be
secondary.
3. When we cover you as a dependent child
and your parents are married (not separated
or divorced):
a. the plan of the parent whose birthday,
month and day, falls earlier in the year
will be primary;
b. if both parents have the same birthday,
month and day, and the other plan has
covered one of the parents longer than
us, we will be secondary.
4. When we cover you as a dependent child
whose parents are not married, or are
separated or divorced:
a. if the parent with custody is not
remarried, the plan of the parent with
custody is primary;
b. if the parent with custody has remarried,
the plan of the parent with custody is
primary; the step - parent's plan is
secondary; and the plan of the parent
without custody is last;
c. regardless of which parent has custody,
when a court decree specifies the
parent who is financially responsible for
the child's health care expenses, the
plan of that parent is always primary.
5. When we cover you as a dependent child
and the other plan covers you as a
dependent child:
a. the plan of the parent who is neither laid
off nor retired will be primary;
b. if the other plan is not subject to this
rule, and if, as a result, such plan does
not agree on the order of benefits, this
paragraph shall not apply.
6. If you have continuation of coverage under
COBRA as a result of the purchase of
coverage as provided under the
Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended,
and also under another group plan, the
following order of benefits applies:
a. first, the plan covering the person as an
employee, or as the employee's
Dependent; and
b. second, the coverage purchased under
the plan covering the person as a former
employee, or as the former employee's
Dependent provided according to the
provisions of COBRA.
7. When rules 1 through 6 above do not
establish an order of benefits, the plan which
has covered the individual the longest shall
be primary, unless you are age 65 or older
and covered under Medicare Parts A and B.
In that case, this Booklet will be secondary
to Medicare.
8. If the other plan does not have rules that
establish the same order of benefits as
under this Booklet, the benefits under the
other plan will be determined primary to the
benefits under this Booklet.
We will not coordinate benefits against an
indemnity -type policy, an excess insurance
policy, a policy with coverage limited to specified
illnesses or accidents, or a Medicare
Supplement policy.
Non - Duplication of Government
Programs and Worker's
Compensation
The benefits under this Booklet shall not
duplicate any benefits to which you or your
Covered Dependents are entitled to or eligible
for under government programs (e.g., Medicare,
Medicaid, Veterans Administration) or Worker's
Compensation to the extent allowed by law, or
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 -2
Section 17: Claims Processing
Introduction
This section is intended to:
• help you understand what you or your
treating Providers must do, under the terms
of this Benefit Booklet, in order to obtain
payment for expenses for Covered Services
they have rendered or will render to you;
and
• provide you with a general description of the
applicable procedures we will use for
making Adverse Benefit Determinations,
Concurrent Care Decisions and for notifying
you when we deny benefits.
Under no circumstances will we be held
responsible for, nor will we accept liability
relating to, the failure of your Group Plan's
sponsor or plan administrator to: 1) comply with
any applicable disclosure requirements;
2) provide you with a Summary Plan Description
(SPD); or 3) comply with any other legal
requirements. You should contact your plan
sponsor or administrator if you have questions
relating to your Group Plan's SPD. We are not
your Group Plan's sponsor or plan administrator
In most cases, a plan's sponsor or plan
administrator is the employer who establishes
and maintains the plan.
Types of Claims
For purposes of this Benefit Booklet, there are
three types of claims: 1) Pre - Service Claims;
2) Post - Service Claims; and 3) Claims Involving
Urgent Care. It is important that you become
familiar with the types of claims that can be
submitted to us and the timeframes and other
requirements that apply.
Post - Service Claims
How to File a Post - Service Claim
We have defined and described the three types
of claims that may be submitted to us. Our
experience shows that the most common type of
claim we will receive from you or your treating
Providers will likely be Post - Service Claims.
In- Network Providers have agreed to file Post -
Service Claims for Services they render to you.
In the event a Provider who renders Services to
you does not file a Post - Service Claim for such
Services, it is your responsibility to file it with us
We must receive a Post - Service Claim within 90
days of the date the Health Care Service was
rendered or, if it was not reasonably possible to
file within such 90 -day period, as soon as
possible. In any event, no Post - Service Claim
will be considered for payment if we do not
receive it at the address indicated on your ID
Card within one year of the date the Service was
rendered unless you were legally incapacitated.
For Post - Service Claims, we must receive an
itemized statement from the health care Provider
for the Service rendered along with a completed
claim form. The itemized statement must
contain the following information:
1. the date the Service was provided;
2. a description of the Service including any
applicable procedure code(s);
3. the amount actually charged by the
Provider;
4. the diagnosis including any applicable
diagnosis code(s);
5. the Provider's name and address;
6. the name of the individual who received the
Service; and
Claims Processing 17 -1
7. the Covered Plan Participant's name and
contract number as they appear on the ID
Card.
The itemized statement and claim form must be
received by us at the address indicated on your
ID Card.
Note: Special claims processing rules may
apply for Health Care Services you receive
outside the state of Florida under the BlueCard
Program (See the `BlueCard (Out -of- State)
Program" section of this Booklet).
The Processing of Post - Service Claims
We will use our best efforts to pay, contest, or
deny all Post - Service Claims for which we have
all of the necessary information, as determined
by us. Post - Service Claims will be paid,
contested, or denied within the timeframes
described below.
• Payment for Post - Service Claims
When payment is due under the terms of this
Benefit Booklet, we will use our best efforts to
pay (in whole or in part) for electronically
submitted Post - Service Claims within 20 days of
receipt. Likewise, we will use our best efforts to
pay (in whole or in part) for paper Post - Service
Claims within 40 days of receipt. You may
receive notice of payment for paper claims
within 30 days of receipt. If we are unable to
determine whether the claim or a portion of the
claim is payable because we need more or
additional information, we may contest the claim
within the timeframes set forth below.
• Contested Post - Service Claims
In the event we contest an electronically
submitted Post - Service Claim, or a portion of
such a claim, we will use our best efforts to
provide notice, within 20 days of receipt, that the
claim or a portion of the claim is contested. In
the event we contest a Post - Service Claim
submitted on a paper claim form, or a portion of
such a claim, we will use our best efforts to
provide notice, within 30 days of receipt, that the
claim or a portion of the claim is contested. Our
notice may identify: 1) the contested portion or
portions of the claim; 2) the reason(s) for
contesting the claim or a portion of the claim;
and 3) the date that we reasonably expect to
notify you of the decision. The notice may also
indicate whether additional information is
needed in order to complete processing of the
claim. If we request additional information, we
must receive it within 45 days of our request for
the information. If we do not receive the
requested information, the claim or a portion
of the claim will be adjudicated based on the
information in our possession at the time
and may be denied. Upon receipt of the
requested information, we will use our best
efforts to complete the processing of the Post -
Service Claim within 15 days of receipt of the
information.
• Denial of Post - Service Claims
In the event we deny a Post - Service Claim
submitted electronically, we will use our best
efforts to provide notice, within 20 days of
receipt, that the claim or a portion of the claim is
denied. In the event we deny a paper Post -
Service Claim, we will use our best efforts to
provide notice, within 30 days of receipt, that the
claim or a portion of the claim is denied. The
notice may identify the denied portion(s) of the
claim and the reason(s) for denial. It is your
responsibility to ensure that we receive all
information determined by us as necessary to
adjudicate a Post - Service Claim. If we do not
receive the necessary information, the claim
or a portion of the claim may be denied.
A Post - Service Claim denial is an Adverse
Benefit Determination and is subject to the
Adverse Benefit Determination standards and
appeal procedures described in this section.
Additional Processing Information for Post -
Service Claims
In any event, we will use our best efforts to pay
or deny all: 1) electronic Post - Service Claims
within 90 days of receipt of the completed claim;
Claims Processing 17 -2
and 2) Post - Service paper claims within 120
days of receipt of the completed claim. Claims
processing shall be deemed to have been
completed as of the date the notice of the claims
decision is deposited in the mail by us or
otherwise electronically transmitted. Any claims
payment relating to a Post - Service Claim that is
not made by us within the applicable timeframe
is subject to the payment of simple interest at
the rate established by the Florida Insurance
Code.
We will investigate any allegation of improper
billing by a Provider upon receipt of written
notification from you. If we determine that you
were billed for a Service that was not actually
performed, any payment amount will be adjusted
and, if applicable, a refund will be requested. In
such a case, if payment to the Provider is
reduced due solely to the notification from you,
we will pay you 20 percent of the amount of the
reduction, up to a total of $500.
Pre - Service Claims
How to File a Pre - Service Claim
This Benefit Booklet may condition coverage,
benefits, or payment (in whole or in part), for a
specific Covered Service, on the receipt by us of
a Pre - Service Claim as that term is defined
herein. In order to determine whether we must
receive a Pre - Service Claim for a particular
Covered Service, please refer to the "What Is
Covered ?" section and other applicable sections
of this Benefit Booklet. You may also call the
customer service number on your ID card for
assistance.
We are not required to render an opinion or
make a coverage or benefit determination with
respect to a Service that has not actually been
provided to you unless the terms of this Benefit
Booklet require (or condition payment upon)
approval by us for the Service before it is
received.
Benefit Determinations on Pre - Service Claims
Involving Urgent Care
For a Pre - Service Claim Involving Urgent Care,
we will use our best efforts to provide notice of
our determination (whether adverse or not) as
soon as possible, but not later than 72 hours
after receipt of the Pre - Service Claim unless
additional information is required for a coverage
decision. If additional information is necessary
to make a determination, we will use our best
efforts to provide notice within 24 hours of: 1)
the need for additional information; 2) the
specific information that you or your Provider
may need to provide; and 3) the date that we
reasonably expect to provide notice of the
decision. If we request additional information,
we must receive it within 48 hours of our
request. We will use our best efforts to provide
notice of the decision on your Pre - Service Claim
within 48 hours after the earlier of: 1) receipt of
the requested information; or 2) the end of the
period you were afforded to provide the
specified additional information as described
above.
Benefit Determinations on Pre - Service Claims
that Do Not Involve Urgent Care
We will use our best efforts to provide notice of a
decision on a Pre - Service Claim not involving
urgent care within 15 days of receipt provided
additional information is not required for a
coverage decision. This 15 -day determination
period may be extended by us one time for up to
an additional 15 days. If such an extension is
necessary, we will use our best efforts to provide
notice of the extension and reasons for it. We
will use our best efforts to provide notification of
the decision on your Pre - Service claim within a
total of 30 days of the initial receipt of the claim,
if an extension of time was taken by us.
If additional information is necessary to make a
determination, we will use our best efforts to:
1) provide notice of the need for additional
information, prior to the expiration of the initial
15 -day period; 2) identify the specific information
Claims Processing 17 -3
that you or your Provider may need to provide;
and 3) inform you of the date that we reasonably
expect to notify you of our decision. If we
request additional information, we must receive
it within 45 days of our request for the
information. We will use our best efforts to
provide notification of the decision on your Pre -
Service Claim within 15 days of receipt of the
requested information.
A Pre - Service Claim denial is an Adverse
Benefit Determination and is subject to the
Adverse Benefit Determination standards and
appeal procedures described in this section.
Concurrent Care Decisions
Reduction or Termination of Coverage or
Benefits for Services
A reduction or termination of coverage or
benefits for Services will be considered an
Adverse Benefit Determination when:
• we have approved in writing coverage or
benefits for an ongoing course of Services to
be provided over a period of time or a
number of Services to be rendered; and
• the reduction or termination occurs before
the end of such previously approved time or
number of Services; and
• the reduction or termination of coverage or
benefits by us was not due to an
amendment of this Benefit Booklet or
termination of your coverage as provided by
this Benefit Booklet.
We will use our best efforts to notify you of such
reduction or termination in advance so that you
will have a reasonable amount of time to have
the reduction or termination reviewed in
accordance with the Adverse Benefit
Determination standards and procedures
described below. In no event shall we be
required to provide more than a reasonable
period of time within which you may develop
your appeal before we actually terminate or
reduce coverage for the Services.
Requests for Extension of Services
Your Provider may request an extension of
coverage or benefits for a Service beyond the
approved period of time or number of approved
Services. If the request for an extension is for a
Claim Involving Urgent Care, we will use our
best efforts to notify you of the approval or denial
of such requested extension within 24 hours
after receipt of your request, provided it is
received at least 24 hours prior to the expiration
of the previously approved number or length of
coverage for such Services. We will use our
best efforts to notify you within 24 hours if: 1) we
need additional information; or 2) you or your
representative failed to follow proper procedures
in your request for an extension. If we request
additional information, you will have 48 hours to
provide the requested information. We may
notify you orally or in writing, unless you or your
representative specifically request that it be in
writing. A denial of a request for extension of
Services is considered an Adverse Benefit
Determination and is subject to the Adverse
Benefit Determination review procedure below.
Standards for Adverse Benefit
Determinations
Manner and Content of a Notification of an
Adverse Benefit Determination
We will use our best efforts to provide notice of
any Adverse Benefit Determination in writing.
Notification of an Adverse Benefit Determination
will include (or will be made available to you free
of charge upon request):
1. the date the Service or supply was provided;
2. the Provider's name;
3. the dollar amount of the claim, if applicable;
4. the diagnosis codes included on the claim
(e.g., ICD -9, DSM -IV), including a
description of such codes;
5. the standardized procedure code included
on the claim (e.g., Current Procedural
Claims Processing 17 -4
Terminology), including a description of such
codes;
6. the specific reason or reasons for the
Adverse Benefit Determination, including
any applicable denial code;
7. a description of the specific Benefit Booklet
provisions upon which the Adverse Benefit
Determination is based, as well as any
internal rule, guideline, protocol, or other
similar criterion that was relied upon in
making the Adverse Benefit Determination;
8. a description of any additional information
that might change the determination and
why that information is necessary;
9. a description of the Adverse Benefit
Determination review procedures and the
time limits applicable to such procedures;
10. if the Adverse Benefit Determination is
based on the Medical Necessity or
Experimental or Investigational limitations
and exclusions, a statement telling you how
to obtain the specific explanation of the
scientific or clinical judgment for the
determination; and
11. You have the right to an independent
external review through an external review
organization for certain appeals, as provided
in the Patient Protection and Affordable
Care Act of 2010.
If the claim is a Claim Involving Urgent Care, we
may notify you orally within the proper
timeframes, provided we follow -up with a written
or electronic notification meeting the
requirements of this subsection no later than
three days after the oral notification.
How to Appeal an Adverse Benefit
Determination
Except as described below, only you, or a
representative designated by you in writing,
have the right to appeal an Adverse Benefit
Determination. An appeal of an Adverse Benefit
Determination will be reviewed using the review
process described below. Your appeal must be
submitted to us in writing for an internal appeal
within 365 days of the original Adverse Benefit
Determination, except in the case of Concurrent
Care Decisions which may, depending upon the
circumstances, require you to file within a
shorter period of time from notice of the denial.
The following guidelines are applicable to
reviews of Adverse Benefit Determinations:
• We must receive your appeal of an Adverse
Benefit Determination in person or in writing;
You may request to review pertinent
documents, such as any internal rule,
guideline, protocol, or similar criterion relied
upon to make the determination, and submit
issues or comments in writing;
• If the Adverse Benefit Determination is
based on the lack of Medical Necessity of a
particular Service or the Experimental or
Investigational exclusion, you may request,
free of charge, an explanation of the
scientific or clinical judgment relied upon, if
any, for the determination, that applies the
terms of this Benefit Booklet to your medical
circumstances;
• During the review process, the Services in
question will be reviewed without regard to
the decision reached in the initial
determination;
• We may consult with appropriate
Physicians, as necessary;
• Any independent medical consultant who
reviews your Adverse Benefit Determination
on our behalf will be identified upon request;
• If your claim is a Claim Involving Urgent
Care, you may request an expedited appeal
orally or in writing in which case all
necessary information on review may be
transmitted between you and us by
telephone, facsimile or other available
expeditious method; and
Claims Processing 17 -5
If you wish to give someone else permission
to appeal an Adverse Benefit Determination
on your behalf, we must receive a
completed Appointment of Representative
form signed by you indicating the name of
the person who will represent you with
respect to the appeal. An Appointment of
Representative form is not required if your
Physician is appealing an Adverse Benefit
Determination relating to a Claim Involving
Urgent Care. Appointment of
Representative forms are available at
www.floridablue.com or by calling the
number on the back of your BCBSF ID Card.
Timing of Our Appeal Review on Adverse
Benefit Determinations
We will use our best efforts to review your
appeal of an Adverse Benefit Determination and
communicate the decision in accordance with
the following time frames:
• Pre - Service Claims -- within 30 days of the
receipt of your appeal; or
• Post - Service Claims -- within 60 days of the
receipt of your appeal; or
• Claims Involving Urgent Care (and requests
to extend concurrent care Services made
within 24 hours prior to the termination of the
Services) -- within 72 hours of receipt of your
request. If additional information is
necessary we will notify you within 24 hours
and we must receive the requested
additional information within 48 hours of our
request. After we receive the additional
information, we will have an additional 48
hours to make a final determination.
Note: The nature of a claim for Services (Le.
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 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.
VA
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
You are entitled to receive, upon written request
and free of charge, reasonable access to, and 4
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.
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.
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.
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.
Non Liability of BCBSF and Monroe
County BOCC
Neither Monroe County BOCC nor any person
covered under this Booklet is BCBSF's agent or
representative, and neither shall be liable for any
acts or omissions by BCBSF's agents, servants,
employees, or us. Additionally, neither BCBSF
Relationship Between the Parties 18 -1
Section 19: General Provisions
Access to Information
BCBSF and Monroe County BOCC have the
right to receive, from you and any health care
Provider rendering Services to you, information
that is reasonably necessary, as determined by
BCBSF and Monroe County BOCC, in order to
administer the coverage and benefits provided,
subject to all applicable confidentiality
requirements listed below. By accepting
coverage, you authorize every health care
Provider who renders Services to you, to
disclose to BCBSF and Monroe County BOCC
or to affiliated entities, upon request, all facts,
records, and reports pertaining to your care,
treatment, and physical or mental Condition, and
to permit BCBSF and /or Monroe County BOCC
to copy any such records and reports so
obtained.
Right to Receive Necessary
Information
In order to administer coverage and benefits,
BCBSF or Monroe County BOCC may, without
the consent of, or notice to, any person, plan, or
organization, obtain from any person, plan, or
organization any information with respect to any
person covered under this Booklet or applicant
for enrollment which BCBSF or Monroe County
BOCC deem to be necessary.
Laws and Regulations
The terms of coverage and benefits to be
provided under this Benefit Booklet shall be
deemed to have been modified and shall be
interpreted, so as to comply with applicable state
or federal laws and regulations dealing with
benefits, eligibility, enrollment, termination, or
other rights and duties.
Confidentiality
Except as otherwise specifically provided herein,
and except as may be required in order for us to
administer coverage and benefits, specific
medical information concerning you, received by
Providers, shall be kept confidential by us in
conformity with applicable law. Such information
may be disclosed to third parties for use in
connection with bona fide medical research and
education, or as reasonably necessary in
connection with the administration of coverage
and benefits, specifically including BCBSF's
quality assurance and Blueprint for Health
Programs. Additionally, we may disclose such
information to entities affiliated with us or other
persons or entities we utilize to assist in
providing coverage, benefits or services under
this Booklet. Further, any documents or
information which are properly subpoenaed in a
judicial proceeding, or by order of a regulatory
agency, shall not be subject to this provision.
Right to Recovery
Whenever the Group Health Plan has made
payments in excess of the maximum provided
for under this Booklet, BCBSF or Monroe
County BOCC will have the right to recover any
such payments, to the extent of such excess,
from you or any person, plan, or other
organization that received such payments.
Compliance with State and Federal
BCBSF's arrangements with a Provider may
require that we release certain claims and
medical information about persons covered
under this Booklet to that Provider even if
treatment has not been sought by or through
that Provider. By accepting coverage, you
hereby authorize us to release to Providers
claims information, including related medical
information, pertaining to you in order for any
such Provider to evaluate your financial
responsibility under this Booklet.
General Provisions 19 -1
Benefit Booklet
You have been provided with this Benefit
Booklet and an Identification Card as evidence
of your coverage under this Benefit Booklet.
Modification of Provider Network and
the Participation Status
NetworkBlue and the Traditional Provider
Program, and the participation status of
individual Providers available through BCBSF,
are subject to change at any time by BCBSF
without prior notice to you or your approval or
that of Monroe County BOCC. Additionally,
BCBSF may, at any time, terminate or modify
the terms of any Provider contract and may
enter into additional Provider contracts without
prior notice to you, or your approval or that of
Monroe County BOCC. It is your responsibility
to determine whether a health care Provider is
an In- Network Provider at the time the Health
Care Service is rendered. Under this Booklet,
your financial responsibility may vary depending
upon a Provider's participation status.
Cooperation Required of You and
Your Covered Dependents
You must cooperate with BCBSF and Monroe
County BOCC, and must execute and submit to
us any consents, releases, assignments, and
other documents requested in order to
administer, and exercise any rights hereunder.
Failure to do so may result in the denial of
claims and will constitute grounds for termination
for cause (See the Termination of an Individual's
Coverage for Cause subsection in the
Termination Of Coverage section).
Non - Waiver of Defaults
Any failure by BCBSF or Monroe County BOCC
at any time, or from time to time, to enforce or to
require the strict adherence to any of the terms
or conditions described herein, will in no event
constitute a waiver of any such terms or
conditions. Further, it will not affect BCBSF's or
Monroe County BOCC's right at any time to
enforce any terms or conditions under this
Benefit Booklet.
Notices
Any notice required or permitted hereunder will
be deemed given if hand delivered or if mailed
by United States Mail, postage prepaid, and
addressed as listed below. Such notice will be
deemed effective as of the date delivered or so
deposited in the mail.
If to BCBSF:
To the address printed on the Identification
Card.
If to you:
To the latest address provided by you or to
your latest address on Enrollment Forms
actually delivered to us.
You must notify Monroe County BOCC
Benefits Office immediately of any
address change.
If to Monroe County BOCC:
To the address indicated by Monroe County
BOCC.
Our Obligations Upon Termination
Upon termination of your coverage for any
reason, there will be no further liability or
responsibility to you under the Group Health
Plan, except as specifically described herein.
Promissory Estoppel
No oral statements, representations, or
understanding by any person can change, alter,
delete, add, or otherwise modify the express
written terms of this Booklet.
General Provisions 19 -2
Florida Agency for Health Care
Administration Performance Data
The performance outcome and financial data
published by the Agency for Health Care
Administration (AHCA), pursuant to Florida
Statute 408.05, or any successor statute,
located at the web site address
www.floridahealthfinder.gov may be accessed
through the link provided on the Blue Cross and
Blue Shield of Florida corporate web site at
www.floridablue.com
Subrogation and Right of Recovery
The provisions of this section apply to all current
or former plan participants and also to the
parents, guardian, or other representative of a
dependent child who incurs claims and is or has
been covered by the plan. The plan's right to
recover (whether by subrogation or
reimbursement) shall apply to the personal
representative of your estate, your decedents,
minors, and incompetent or disabled persons.
"You" or "your' includes anyone on whose behalf
the plan pays benefits. No adult Covered Person
hereunder may assign any rights that it may
have to recover medical expenses from any
tortfeasor or other person or entity to any minor
child or children of said adult covered person
without the prior express written consent of the
Plan.
The plan's right of subrogation or
reimbursement, as set forth below, extend to all
insurance coverage available to you due to an
injury, illness or condition for which the plan has
paid medical claims (including, but not limited to,
liability coverage, uninsured motorist coverage,
underinsured motorist coverage, personal
umbrella coverage, medical payments coverage,
workers compensation coverage, no fault
automobile coverage or any first party insurance
coverage).
For the purpose of determining payment of
benefits, your health plan is always secondary to
automobile no -fault coverage, personal injury
protection coverage, or medical payments
coverage.
By accepting benefits under this Booklet, you
specifically acknowledge our right of subrogation
and reimbursement. These rights apply to any
claim or potential claim made by you or on your
behalf from the following sources, jncluding but
not limited to:
• Payments made by a Third Party or any
insurance company on behalf of the
Third Party;
• Any payments or awards under an
uninsured or underinsured motorist
coverage policy;
• Any Workers' Compensation or disability
award or settlement;
• Medical payments under any
automobile, homeowners' or premises
liability policy; and
• Any other payments from any source
intended to compensate you for injuries
resulting from an accident or alleged
negligence.
By accepting benefits under this Booklet, you
also agree to:
• Notify us promptly and in writing when
notice is given to any party of the
intention to investigate or pursue a
claim, or of settlement negotiations with
Third Parties, prior to entering into any
settlement agreement; and
• Notify us promptly of any amounts
recovered from Third Parties, by way of
settlement or judgment, and do not
distribute the settlement 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 et seq, to
share your personal health information in
exercising its subrogation and reimbursement
rights.
Interpretation
In the event that any claim is made that any part
of this subrogation and right of recovery
provision is ambiguous or questions arise
concerning the meaning or intent of any of its
terms, the Claims Administrator for the plan shall
have the sole authority and discretion to resolve
all disputes regarding the interpretation of this
provision.
Jurisdiction
By accepting benefits from the Plan, you agree
that any court proceeding with respect to this
General Provisions 19 -5
provision may be brought in any court of
competent jurisdiction as the plan may elect. By
accepting such benefits, you hereby submit to
each such jurisdiction, waiving whatever rights
may correspond by reason of your present or
future domicile. By accepting such benefits, you
also agree to pay all attorneys' fees the plan
incurs in successful attempts to recover
amounts the plan is entitled to under this
section.
Third Party Beneficiary
The terms and provisions of the Group Health
Plan shall be binding solely upon, and inure
solely to the benefit of, Monroe County BOCC
and individuals covered under the terms of this
Benefit Booklet, and no other person shall have
any rights, interest or claims thereunder, or
under this Benefit Booklet, or be entitled to sue
for a breach thereof as a third -party beneficiary
or otherwise. Monroe County BOCC hereby
specifically expresses its intent that health care
Providers that have not entered into contracts
with BCBSF to participate in BCBSF's Provider
networks shall not be third -party beneficiaries
under the terms of the Monroe County BOCC
Group Health Plan or this Benefit Booklet.
Customer Rewards Programs
From time to time, we may offer programs to our
customers that provide rewards for following the
terms of the program. We will tell you about any
available rewards programs in general mailings,
member newsletters and /or on our website.
Your participation in these programs is
completely voluntary and will in no way affect
the coverage available to you under this Benefit
Booklet. We reserve the right to offer rewards in
excess of $25 per year as well as the right to
discontinue or modify any reward program
features or promotional offers at any time
without your consent.
General Provisions 19 -6
Section 20: Definitions
The following definitions are used in this Benefit
Booklet. Other definitions may be found in the
particular section or subsection where they are
used.
Accident means an unintentional, unexpected
event, other than the acute onset of a bodily
infirmity or disease, which results in traumatic
injury. This term does not include injuries
caused by surgery or treatment for disease or
illness.
Accidental Dental Injury means an injury to
sound natural teeth (not previously
compromised by decay) caused by a sudden,
unintentional, and unexpected event or force.
This term does not include injuries to the mouth,
structures within the oral cavity, or injuries to
natural teeth caused by biting or chewing,
surgery, or treatment for a disease or illness.
Administrative Services Only Agreement or
ASO Agreement means an agreement between
Monroe County BOCC and BCBSF. Under the
Administrative Services Only Agreement,
BCBSF provides claims processing and
payment services, customer service, utilization
review services and access to BCBSF's
NetworkBlue and BCBSF's network of
Traditional Insurance Providers.
Adverse Benefit Determination means any
denial, reduction or termination of coverage,
benefits, or payment (in whole or in part) under
the Benefit Booklet with respect to a Pre - Service
Claim or a Post - Service Claim. Any reduction or
termination of coverage, benefits, or payment in
connection with a Concurrent Care Decision, as
described in this section, shall also constitute an
Adverse Benefit Determination.
Allowed Amount means the maximum amount
upon which payment will be based for Covered
Services. The Allowed Amount may be changed
at any time without notice to you or your
consent.
1. In the case of an In- Network Provider
located in Florida, this amount will be
established in accordance with the
applicable agreement between that Provider
and BCBSF.
2. In the case of an In- Network Provider
located outside of Florida, this amount will
generally be established in accordance with
the negotiated price that the on -site Blue
Cross and /or Blue Shield Plan ( "Host Blue ")
passes on to us, except when the Host Blue
is unable to pass on its negotiated price due
to the terms of its Provider contracts. See
the BlueCard (Out -of- State) Program
section for more details.
3. In the case of Out -of- Network Providers
located in Florida who participate in the
Traditional Program, this amount will be
established in accordance with the
applicable agreement between that Provider
and BCBSF.
4. In the case of Out -of- Network Providers
located outside of Florida who participate in
the BlueCard (Out -of- State) Traditional
Program, this amount will generally be
established in accordance with the
negotiated price that the Host Blue passes
on to us, except when the Host Blue is
unable to pass on its negotiated price due to
the terms of its Provider contracts. See the
BlueCard (Out -of- State) Program section for
more details.
5. In the case of an Out -of- Network Provider
that has not entered into an agreement with
BCBSF to provide access to a discount from
the billed amount of that Provider for the
specific Covered Services provided to you,
the Allowed Amount will be the lesser of that
Provider's actual billed amount for the
specific Covered Services or an amount
established by BCBSF that may be based
on several factors including (but not
Definitions 20 -1
necessarily limited to): (i) payment for such
Services under the Medicare and /or
Medicaid programs; (ii) payment often
accepted for such Services by that Out -of-
Network Provider and /or by other Providers,
either in Florida or in other comparable
market(s), that BCBSF determines are
comparable to the Out -of- Network Provider
that provided the specific Covered Services
(which may include payment accepted by
such Out -of- Network Provider and /or by
other Providers as participating providers in
other provider networks of third -party payers
which may include, for example, other
insurance companies and /or health
maintenance organizations); (iii) payment
amounts which are consistent, as
determined by BCBSF, with BCBSF's
provider network strategies (e.g., does not
result in payment that encourages Providers
participating in a BCBSF network to become
non - participating); and /or, (iv) the cost of
providing the specific Covered Services. In
the case of an Out -of- Network Provider that
has not entered into an agreement with
another Blue Cross and /or Blue Shield
organization to provide access to discounts
from the billed amount for the specific
Covered Services under the BlueCard (Out -
of- State) Program, the Allowed Amount for
the specific Covered Services provided to
you may be based upon the amount
provided to BCBSF by the other Blue Cross
and /or Blue Shield organization where the
Services were provided at the amount such
organization would pay non - participating
Providers in its geographic area for such
Services.
You may obtain an estimate of the Allowed
Amount for particular Services by calling the
customer service telephone number included in
this Booklet or on your Identification Card. The
fact that we may provide you with such
information does not mean that the particular
Service is a Covered Service. All terms and
conditions included in your Booklet apply. You
should refer to the 'What is Covered ?" section of
your Booklet and the Schedule of Benefits to
determine what is covered and how much will be
paid.
Please specifically note that, in the case of an
Out -of- Network Provider that has not entered
into an agreement with BCBSF to provide
access to a discount from the billed amount of
that Provider, the Allowed Amount for particular
Services is often substantially below the amount
billed by such Out -of- Network Provider for such
Services. You will be responsible for any
difference between such Allowed Amount and
the amount billed for such Services by any such
Out -of- Network Provider.
Ambulance means a ground or water vehicle,
airplane or helicopter properly licensed pursuant
to Chapter 401 of the Florida Statutes, or a
similar applicable law in another state.
Ambulatory Surgical Center means a facility
properly licensed pursuant to Chapter 395 of the
Florida Statutes, or a similar applicable law of
another state, the primary purpose of which is to
provide elective surgical care to a patient,
admitted to, and discharged from such facility
within the same working day.
Applied Behavior Analysis means the design,
implementation and evaluation of environmental
modifications, using behavioral stimuli and
consequences to produce socially significant
improvement in human behavior, including, but
not limited to, the use of direct observation,
measurement and functional analysis of the
relations between environment and behavior.
Approved Clinical Trial means a phase I,
phase II, phase III, or phase IV clinical trial that
is conducted in relation to the prevention,
detection, or treatment of cancer or other Life -
Threatening Disease or Condition and meets
one of the following criteria:
Definitions 20 -2
1. The study or investigation is approved or
funded by one or more of the following:
a. The National Institutes of Health.
b. The Centers for Disease Control and
Prevention.
c. The Agency for Health Care Research
and Quality.
d. The Centers for Medicare and Medicaid
Services.
e. Cooperative group or center of any of
the entities described in clauses (i)
through (iv) or the Department of
Defense or the Department of Veterans
Affairs.
f. A qualified non - governmental research
entity identified in the guidelines issued
by the National Institutes of Health for
center support grants.
g. Any of the following if the conditions
described in paragraph (2) are met:
L 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 1 st 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 204
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
Definitions 20 -7
an institutional review board or other entity
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,
Definitions 20 -8
effectiveness, or effectiveness compared
with standard alternatives.
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
Definitions 20 -9
regularly makes available at least clinical
laboratory services, diagnostic x -ray services
and treatment facilities for surgery or obstetrical
care or other definitive medical treatment of
similar extent.
The term Hospital does not include: an
Ambulatory Surgical Center; a Skilled Nursing
Facility; a stand -alone Birthing Center; a
Psychiatric Facility; a Substance Abuse Facility;
a convalescent, rest or nursing home; or a
facility which primarily provides Custodial,
educational, or Rehabilitative Therapies.
Note: If services specifically for the
treatment of a physical disability are
provided in a licensed Hospital which is
accredited by the Joint Commission on the
Accreditation of Health Care Organizations,
the American Osteopathic Association, or
the Commission on the Accreditation of
Rehabilitative Facilities, 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
Domestic Partner Coverage Endorsement
This Endorsement is to be attached to and made
a part of the current Benefit Booklet and any
Endorsements attached thereto. The Benefit
Booklet is amended as described below to
provide coverage for a Domestic Partner of a
Covered Employee (employee only) and, if
applicable, the dependent child(ren) of a
Domestic Partner.
Glossary of Terms
Domestic Partner means a person of the same
or opposite sex with whom the Covered
Employee (employee only) has established a
Domestic Partnership.
6. the Covered Employee has completed and
submitted any required forms to the Group
and the Group has determined the Domestic
Partnership eligibility requirements have
been met.
Eligibility for Coverage
Domestic Partner and Dependent Child(ren)
of Domestic Partners Eligibility
The following individuals are eligible to apply for
coverage under the Benefit Booklet:
1. the Covered Employee's (employee only)
present Domestic Partner;
Domestic Partnership means a relationship
between a Covered Employee (employee only)
and one other person of the same or opposite
sex who meet at a minimum, the following
eligibility requirements:
1. both individuals are each other's sole
Domestic Partner and intend to remain so
indefinitely;
2. individuals are not related by blood to a
degree of closeness (e.g., siblings) that
would prohibit legal marriage in the state in
which they legally reside;
3. both individuals are unmarried, at least 18
years of age, and are mentally competent to
consent to the Domestic Partnership;
4. both individuals are financially
interdependent and have resided together
continuously in the same residence for at
least six months prior to applying for
coverage under the Benefit Booklet and
intend to continue to reside together
indefinitely;
5. the Covered Employee has submitted to the
Group acceptable proof of evidence of
common residence and joint financial
responsibility; and
2. the Covered Domestic Partner's dependent
child(ren), who is under the limiting age, who
meets all of the following eligibility
requirements, and the eligibility requirements
under the Benefit Booklet:
a. resides regularly with the Covered
Employee and the Domestic Partner, or
the Domestic Partner is required to
provide coverage for the child(ren) by
court order; or
b. the child(ren) qualifies as the Domestic
Partner's dependent(s) for tax purposes
under the federal guidelines; and
c. the child(ren) meets and continues to
meet the eligibility requirements as
outlined in the Eligibility Requirements
for Dependent(s) subsection of the
Benefit Booklet.
Domestic Partner Enrollment Forms/
Electing Coverage
When an Eligible Employee is making
application for coverage for his /her Domestic
Partner and the Domestic Partner's dependent
child(ren), the Eligible Employee must complete
ASO Dom Part with Dep END
Plan 03559
and submit through the Group any required
Enrollment Forms. When an Eligible Employee
is electing coverage for his /her self and his /her
Domestic Partner, and Employee /Spouse
Coverage is available under the Group's
program, Employee /Spouse Coverage is
redefined as Employee /Domestic Partner
Coverage.
Domestic Partner Enrollment Periods
An Eligible Employee may make application for
an eligible Domestic Partner and the Domestic
Partner's dependent child(ren) during the
following enrollment periods and as outlined in
the Benefit Booklet:
1. employee's Initial Enrollment Period;
2. Annual Open Enrollment Period;
3. Special Enrollment Period; or
4. within the 30 -day period immediately
following the satisfaction of the eligibility
requirements of the Domestic Partnership.
Termination of a Domestic Partner's
and /or Domestic Partner's Dependent
Child(ren)'s Coverage
In addition to the provisions stated in the
Termination of a Covered Dependent's
Coverage subsection of the Benefit Booklet, the
Covered Domestic Partner's and the Covered
Domestic Partner's Covered Dependent
child(ren)'s coverage under the Benefit Booklet
will terminate at 12:01 a.m. on the date that the
Domestic Partnership terminates or the date of
death of the Covered Domestic Partner. The
Covered Employee must notify the Group within
30 days of when Domestic Partnership eligibility
requirements are no longer met or within 30
days of the death of the Covered Domestic
Partner.
COBRA Continuation of Coverage
Covered Domestic Partners are not entitled to
COBRA continuation of coverage but are eligible
under Monroe County employment/personnel
rules to apply for continuation of coverage under
the MCBCC Group Health Plan.
Miscellaneous
The term Eligible Dependent is modified to also
include the reference to Domestic Partner when
spouse is referenced.
This Endorsement shall not extend, vary, alter,
replace, or waive any of the provisions, benefits,
exclusions, limitations, or conditions contained in
the Benefit Booklet, other than as specifically
stated in the provisions contained in this
Endorsement. In the event of any
inconsistencies between the provisions
contained in this Endorsement and the
provisions contained in the Benefit Booklet, the
provisions contained in this Endorsement shall
control to the extent necessary to effectuate the
intent as expressed herein.
Serviced By
Blue Cross and Blue Shield of Florida, Inc.
ASO Dom Part with Dep END
Plan 03559
County of Monroe
The Florida Keys
C.19.i
110ARD OF COUN I'1 COMMISSIONERS
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DannN i kolhage. Di•drict I
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County Commission Meeting
February 15, 2017
Agenda Item Summary #2642
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez - Gonzalez (305)
292 -4448
N A
AGENDA ITEM WORDING: Approval of Amendment to Employee Benefit Consulting; Services
Agreement with Gallagher Benefit Senfices (GBS) extending, the contract through December 30.
2418 and approving a one -time fee of $25,000 for additional services of Health Care Analytics to
evaluate expected pharmacy benefits management (PBM) proposals the County receives during
2017 after issuance of a Request for Proposal (RFP) and acceptance of the Client Coverage
Acknowledgment & Compensation Disclosure Statement
ITEM BACKGROUND: The County Commission requested staff issue a total of four (4) Requests
for Proposals (RFPs) during 2017 and 2018 including:
I. Pharmacy Benefits Management (PBM) program;
—42. Fully insured health insurance program;
3. Self- insured health insurance program: and
4. Stop loss policy for the self - insured health insurance program
The timing of these RFPs must be coordinated with the existing contract term with our current
Pharmacy vendor. Envision (contrac( expires 12 31 2017) and our current Self Insured TPA.
Florida Blue (contract expires 12. V2020) with a $154.004 early terrnination fee.
Attached is a recommended timeline for issuance of these RFPs.
Given these dales. County staff is recommending an extension of our agreement with Gallagher
Benefits Services (GBS) through December 30, 2018 in order to ensure proper evaluation of the
RFPs and proper implementation with the new vendors.
Further. GBS has developed a new process for evaluating pharmacy beneFtts proposals to assure
a comprehensive. proprietary PBM pricing model that quantitatively evaluates and adjust all
proposals for pharmacy benefits by collecting current PBM usage from the County's existing
PBM plan: preparing, a financial and non - financial analysis of the proposals.
I Iealth Care Ana Iytics (1 CA) fee for evaluating the pharmacy benefits management (1 BM)
proposals cost a one -time fee of $25.000. The additional HCA service will provide real value in
Packet Pg. 723
C.19.i
e\ a[uatina tlic 1 proposals lo: the P13NI pr grain- ,%I. o lac Iuded is a Client Co erage
AcknoNNIedgment and Compen ation Disclo .�.rc Staten ei:t ['.! acceptance by the BOCC.
PREVIOLIS RELEVANT BOCC ACTION:
+ September 15 - 20 10 NICBOCC entered into an greci..ent % ith Gallagher Benefits Services
(GBS) to prox ide consulting scr� ices in the area f'Group l-lealth insurance:
• April 17. 2013 agreenent , ,1lth GBS to renel% for one (1) year and subsequentll renewed at
the County's option for two (2) additional consecuti%e one vear terms;
• October 1, 2016 agreement extended for one (1) additional year through September 20, 2017
CONTRACT/AGREEMENT CHANGES:
Renew agreement until Dec. 30. 2018 with no increase in their service fee
STAFF RECOMMENDATION: Approval of amendment and approval to utilize the services of
I lealth Care Analytics to evaluate the PMB proposals received in the 2017 RFP. Acceptance of
Client Coverage Acknowledgment and Compensation Disclosure Statement.
DOCUMENTATiON:
GBS 2017 AMENDMENT
GBS 2017 CLIENT COVERAGE ACKNOWLEDGEMENT AND COMPENSATION
DISCLOSURE STATEMENT
GBS 2010 CONTRACT
GBS RENEWAL 2013
GBS RENEWAL 2016
MCBCC PBM Procurement summary
2017.2018 RFP Timelines Group Health Plan
FINANCIAL IMPACT:
Effective Date: February 15, 2017
Expiration Date: December 31, 2018
Total Dollar Value of Contract: S150,000/year plus a one time additional $25,000 for
i additional services being added (Pharmacy Benefit Manager Proposals)
Total Cost to County: $325,000
Current Year Portion: 5125,000
Budgeted: YES
Source of Funds: Health Insurance Fund
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing: If yes, amount:
Grant:
Count Match:
Packet Pg. 724
C.19.i
Insurance Required:
Additional Details:
02 15 17 502 -08001 - GROUP INS ADMIN
increase to co%cr I ICA ser%ice for I RFP anal%sis
REVIEWED BY:
Christine Hurley
Completed
Budget and Finance
Completed
Christine Limbert
Completed
Maria Slavik
Completed
Kathy Peters
Completed
Board of County Commissioners
Pending
525.000.00
01/31!2017 4:58 PM
02/01/2017 8:23 AM
02/01/2017 12:53 PM
02/01/2017 1 2:55 PM
02 01 /2017 12:59 PM
02/1512017 9:00 AM
Packet Pg. 725
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