Item C14'
CM
ounty of onroe
BOARD OF COUNTY COMMISSIONERS
Mayor Heather Carruthers, District 3
Mayor Pro Tem George Neugent, District 2
TheFloridaKeys
Danny L. Kolhage, District 1
David Rice, District 4
Sylvia J. Murphy, District 5
County Commission Meeting
May 18, 2016
Agenda Item Number: C.14
Agenda Item Summary #1637
BULK ITEM: DEPARTMENT:
Yes Employee Services
TIME APPROXIMATE:STAFF CONTACT:
Maria Fernandez-Gonzalez (305)
292-4448
<Type In>
AGENDA ITEM WORDING:
Approval to Advertise a Request for Proposals for Fully Insured
Vision Benefits for eligible active employees and retirees.
ITEM BACKGROUND:
The County offers vision insurance to eligible employees and retirees.
Those who elect coverage pay 100% of the cost. The County's current vision insurance provider is
Vision Service Plan Insurance Company (VSP). They have been the provider since 2011 (5 years).
The last Vision RFP was done in 2011 and VSP was granted a 2 year contract. On September 17,
2013 the BOCC granted a three year renewal with some enhancements and no premium increase,
bringing the expiration of the contract currently set for December 31, 2016. In order to have a vision
provider on board, prior to open enrollment in the Fall of 2016, this RFP needs to begin now.
Current benefits, as well as a timeline for receiving proposals, are shown in the attached RFP.
The County has invited constitutional officers to participate in the selection process. The following
staff members are on the selection committee: Teresa Aguiar, Employee Services Director; Maria
Gonzalez, Sr. Benefits Administrator; Jane Isherwood, Court Administration; Donna Moore,
Sheriff; Joyce Griffin, Supervisor of Elections; Pam Radloff, Clerk of Court; Cathy Crane, Tax
Collector.
PREVIOUS RELEVANT BOCC ACTION: April 17, 2003, BOCC approved recommendation
to make vision benefits voluntary and fully-insured.
October 2003 - BOCC approved American General (carrier from 1/1/04 - 12/31/07)
November 2007 - BOCC approved EyeMed (carrier from 1/1/08 - 12/31/11)
October 2011 - BOCC approved VSP (carrier from 1/1/12 - 12/31/16)
CONTRACT/AGREEMENT CHANGES:
n/a
STAFF RECOMMENDATION:
Approval
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DOCUMENTATION:
MONROE COUNTY 2016 - VISION RFP
Exhibit A - Scope-of-Services
Exhibit B - Vision Questionnaire
Exhibit C - Benefit Offering
Attachment A - Vision Plan Documentation
Attachment B - Vision Claims History
Attachment C - Census and Enrollment
Attachment D - Current Vision Rates
FINANCIAL IMPACT:
Effective Date: N/A
Expiration Date:
Total Dollar Value of Contract: $300.00
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: If yes, amount:
Grant:
County Match
:
Insurance Required:
Additional Details: Vision premiums are expected to exceed $97,000 upon renewal. No cost
to Monroe County. All premiums paid by participants.
05/18/16 502-08001 · GROUP INS ADMIN $300.00
REVIEWED BY:
Teresa Aguiar Completed 05/02/2016 3:21 PM
Christine Hurley Completed 05/03/2016 8:41 AM
Cynthia Hall Completed 05/03/2016 9:56 AM
Budget and Finance Completed 05/03/2016 4:29 PM
Maria Slavik Completed 05/03/2016 5:03 PM
Kathy Peters Completed 05/03/2016 5:10 PM
Board of County Commissioners Pending 05/18/2016 9:00 AM
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FULLY INSURED VISION BENEFITS
BOARD OF COUNTY COMMISSIONERS
Mayor, Heather Carruthers, District 3
Mayor Pro Tem, George Neugent, District 2
Danny L. Kolhage, District 1
David Rice, District 4
Sylvia J. Murphy, District 5
COUNTY ADMINISTRATOR
Roman Gastesi
CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION
Amy Heavilin Employee Benefits
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NOTICE OF REQUEST FOR COMPETITIVE SOLICITATIONS
NOTICE IS HEREBY GIVEN June 28, 2016 at 3:00 P.M.,
that on the Monroe County
Purchasing Office will receive and open sealed responses for the following:
FULLY-INSUREDVISIONBENEFITS
MONROECOUNTY,FLORIDA
Requirements for submission and the selection criteria may be requested from DemandStar
www.demandstar.comwww.monroecountybids.com
by Onvia at OR or call toll-free at 1-
800-711-1712. The Public Record is available at the Monroe County Purchasing Office
located at The Gato Building, 1100 Simonton Street, Room 2-213, Key West, Florida. All
Responses must be sealed and must be submitted to the Monroe County Purchasing Office.
Publication dates
Citizen: Wed. May 25, 2016
Keynoter: Wed. May 25, 2016
Reporter: Fri. May 27, 2016
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SECTION ONE - INSTRUCTIONS TO PROPOSERS
SECTION TWO - COUNTY FORMS
EXHIBITS: EXHIBIT A SCOPE OF SERVICES
EXHIBIT B VISION QUESTIONNAIRE
EXHIBIT C BENEFIT OFFERING
ATTACHMENTS: A. VISION PLAN DOCUMENTATION
B. VISION CLAIMS HISTORY
C. CENSUS AND ENROLLMENT
D. CURRENT VISION RATES
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The County is seeking an insurance vendor to provide the County with options for a
dual choice fully insured Vision Proposal for its active employees, dependents, COBRA,
and retired employees in accordance with the specifications outlined in this Request for
Proposals.
The County anticipates that this contract will be awarded for an effective date of
January 1, 2017. The initial policy term may be up to thirty six (36) months and the
County may elect to renew for up to two (2) additional consecutive 1 year terms. The
policy term will be dependent upon the acceptability of premium guarantees,
coverage, service, provider stability and market conditions.
The County is requesting Proposals for Vision insurance as follows:
Contributions: 100% Participant Paid
Plans Requested: The County is requesting that Proposers provide both a Low Option
Vision Plan and a High Option Vision Plan. The County currently offers the Low Option
Vision Plan to its members, but wishes to explore the possibility of offering a plan with
additional benefits (“High Option Vision Plan”).
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IRLERGIQIRXWGERFISJJIVIHEXQSVIGSQTIXMXMZIVEXIWXLI'SYRX][MPPIZEPYEXI
XLISJJIVIHTPERW4PIEWIVIJIVXSXLITSPMG]HSGYQIRXWJSVXLII\EGXFIRIJMX
WTIGMJMGEXMSRWProposers are asked to indicate their ability to provide these benefits
on)\LMFMX'.
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WellVision Exam $10 $45
Materials $20 See below
Frame $140 Allowance
$70
20% discount over allowance
Lenses
Single Vision Lenses Included in Prescription
$30
Glasses
Lined Bifocal Included in Prescription
$50
Glasses
Lined Trifocal Included in Prescription
$65
Glasses
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Lens Enhancements
Standard progressive
$55N/A
lenses
Premium progressive
$95 - $105 N/A
lenses
Custom progressive
$150 - $175 N/A
lenses
Average savings of 20-25% on
other lens enhancements
Contacts (instead of $115 Allowance; copay does
$105.00
glasses) not apply
Contact lens exam
Up to $60 N/A
(fitting & evaluation)
Medically Necessary
$210 Allowance
Contact Lenses
Services related to diabetic
eye disease, glaucoma and
age-related macular
(MEFIXMG)]IGEVI4PYWdegeneration (AMD). Retinal
screening for eligible members
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with diabetes. Limitations and
coordination with medical
coverage may apply.
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Extra 20% to spend on
featured frame brands. Go to
vsp.com/special offers for
details.
20% savings on additional
Glasses & Sunglasses
glasses & sunglasses,
including lens enhancements,
from any VSP provider within
12 months of your last
WellVision Exam
No more than a $39 copay on
routine retinal screening as an
Retinal Screening
enhancement to a WellVision
Exam
Average 15% off the regular
price of 5% off the promotional
Laser Vision Correction
price; discounts only available
from contracted facilities
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Copay
UV Coating Included in Prescription
Please provide
Glasses
Standard Polycarbonate $10 Copayment Please provide
Anti-Reflective Coating $40 Copayment Please provide
Premium Progressives $55 Copayment Please provide
Photochromic Lenses $30 Copayment Please provide
Frame $180 Allowance Please provide
Contacts (instead of Please provide
$130 Allowance
glasses)
Proposals are requested to be submitted net of commissions, although it is not required.
If any compensation for an agent is included in the rates, this must be fully disclosed
along with the exact services the agent will be providing to the County. Please note that
any entity and/or person who participated in the drafting of this RFP is disqualified from
submitting a proposal in response to this RFP or receiving a commission as a result of
the award of a contract for services arising out of this RFP.
The County intends to follow the following dates as closely as possible:
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Monroe County is a non-charter county and a political subdivision of the State of
Florida. The County population is approximately 73,000. The Board of County
Commissioners, constituted as the governing body, has all the powers of a body
corporate, including the powers to contract; to sue and be sued; to acquire, purchase,
hold, lease and convey real estate and personal property; to borrow money and to
generally exercise the powers of a public authority organized and existing for the
purpose of providing community services to citizens within its territorial boundaries. In
order to carry out this function, the County is empowered to levy taxes to pay the cost of
operations.
Monroe County is the southernmost county in the United States. It is comprised of the
Florida Keys and a portion of the Florida Everglades. The Florida Keys are an
archipelago of islands stretching from Key West, only 90 miles from Cuba, up to the
mainland. In addition to the unincorporated county, there are five municipalities in the
Florida Keys: Key West, Marathon, Key Colony Beach, Layton, and Islamorada.
Further information about the demographics of the County can be found here:
http://www.monroecounty-fl.gov/index.aspx?NID=27 .
Approximately one-third of the population is situated in the City of Key West, which is
the county seat; however, the County offers services throughout the Keys, and has
government buildings throughout the Lower Keys (primarily Big Pine Key), Middle Keys
(primarily Marathon), and Upper Keys (primarily Plantation Key and Key Largo) in
addition to Key West, with employees stationed in all locations.
4VIWIRX-RJSVQEXMSR
Monroe County currently offers one voluntary fully insured vision plan to active
employees, dependents, retirees, COBRA eligibles, and Surviving Spouses. Premiums
are paid for by active employees through payroll deductions. 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 and forwarded to the carrier
by Monroe 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 Resolution (Resolution Number 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.
Current rates are included in Attachment D and do not include commissions. The rates
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for the vision plan have not changed since implementation in 2012. The High Option
will be a new plan effective 1/1/2017.
The current plan is offered by VSP, which has provided coverage since 2012.
'SQTIRWEXMSR Proposer shall be in compliance with Section 624.428, Florida
Statutes.If any commissions and/or service fees are included in your rate quotation,
you shall specify the amount of the commissions and/or service fees, to whom they may
be paid and your reason(s) for including them.
The Monroe County Board of County Commissioners has engaged an independent
consultant, Gallagher Benefit Services, Inc., to develop the RFP, provide analysis of
Proposals to the Selection Committee with regard to the RFP, and for ongoing servicing
of the contract.
The consultants are paid a fee from the County for these services and are not eligible to
receive a fee or commission from any proposer or to submit a proposal on behalf of any
agency, broker, or carrier with regard to this RFP.
)ZEPYEXMSR'VMXIVME
A Selection Committee will be convened to review the Proposals and recommend which
Insurance vendor should be selected for the project. The successful Proposer will be selected
based on the following criteria.
PPO Network accessibility for all participants as measured 30 points
though a GeoAccess network match
Costs and rate guarantees 30points
Ability to provide the Scope of Services (implementation 20points
timeframe will be critical in assessing services)
Compliance with RFP Specifications 10 points
Prior experience with government clients 5 points
Location of firm (local preference if applicable: up to 5 5 points
additional points)
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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 Insurance vendor should be hired.
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Requests for additional information or clarification relating to the specifications of this
Request for Proposals shall be submitted MR[VMXMRK directly to:
Maria Fernandez-Gonzalez, Benefits Administrator
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 41.YRI
. 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 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.
'SRXIRXSJ7YFQMWWMSR
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.
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The Proposalshall include the following:
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A cover page that states "Request for Proposals for Fully Insured Vision Benefits”The
cover page should contain Proposer's name, address, telephone number, and the name
of the Proposer's contact person(s).
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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.
8EF1MRMQYQ5YEPMJMGEXMSRW
The Proposer shall be licensed in the State of Florida to provide the requested
insurance.
The Proposer shall provide financial rating information from at least two (2) of the
recognized financial rating companies (i.e. Moody’s, Fitch, Standard & Poor’s) for
the most recent three (3) years available.
If the Proposer is not rated by any of the financial rating companies or if the rating is
lower than A, 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 dental insurance coverage within the past three (3) years. At least
two (2) of these references must be from other city or county governments within the
State of Florida. Each reference at a minimum shall include:
Name and full address of the client;
o
Name, address, title, and telephone number of the client contact;
o
Identification of coverage provided, including years for which the coverage was
o
offered.
The Proposer shall include at least two 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 for “prior experience with government clients.”
8EF7GSTISJ7IVZMGIW
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.
8EF5YIWXMSRREMVIERH'SWX4VSTSWEP
Please include the completed Questionnaire (Exhibit B) under this tab in the file format
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as provided in the RFP package. Responses should be succinct while providing
sufficient information to reply to the specific question.)\GIWWMZIPERKYEKIMWRSX
HIWMVIH.
The fee (premiums) for the insurance coverage described in this RFP shall be included
in the Questionnaire. The fee shall be 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.
It is not anticipated that contingencies will be included in the Proposal. However, please
include your underwriting assumptions under this Tab 4, immediately after the
Questionnaire.
8EF7XEJJMRKJSVXLMW4VSNIGXERH5YEPMJMGEXMSRWSJ/I]4IVWSRRIP
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. %R]ETTPMGERXSXLIVXLERERMRHMZMHYEP
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QYWXWYFQMXETVMRXSYXSJXLIw(IXEMPF])RXMX]2EQIxWGVIIRJVSQ7YRFM^ERHE
GST]SJXLIQSWXVIGIRXERRYEPVITSVXJMPIH[MXLXLI*PSVMHE(ITEVXQIRXSJ7XEXI
(MZMWMSRSJ'SVTSVEXMSRW
If the Proposer is anything other than an individual or sole proprietorship, the 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 also describe the qualifications for each employee on the project team and identify
his/her role on the team. Include in this section the location of the main office and the
location of the office proposed to work on this project.
8EF3XLIV-RJSVQEXMSR
Tab 6 shall include:
Exhibit C – Benefit Offering
GeoAccess Reports;
List of network providers as described in Question 11 in the Network Providers
Section of the Vision Questionnaire (Exhibit B).
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 (other than those addressed
in the Scope of Services) contained in the Request for Proposals, all deviations to the
terms must be spelled out in this section, i.e. Tab 6.
8EF0MXMKEXMSR
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In accordance with Section 2-347(h) of the Monroe County Code, the Proposer must
provide the following information:
(1) A list of the person’s or entity’s shareholders with five (5) percent or more of the
stock or, if a general partnership, a list of the general partners; or, if a limited
liability company, a list of its members; or, if a solely owned proprietorship,
names(s) of owner(s);
(2) A list of the officers and directors of the entity;
(3) The number of years the person or entity has been operating and, if different, the
number of years it has been providing the services, goods, or construction
services called for in the bid specifications (include a list of similar projects);
(4) The number of years the person or entity has operated under its present name
and any prior names;
(5) Answers to the following questions regarding claims and suits:
a. Has the person, principals, entity, or any entity previously owned, operated
or directed by any of its officers, major shareholders or directors, ever failed
to complete work or provide the goods for which it has contracted? If yes,
provide details;
b. Are there any judgments, claims, arbitration proceeding or suits pending or
outstanding against the person, principal of the entity, or entity, or any entity
previously owned, operated or directed by any of its officers, directors, or
general partners? If yes, provide details;
c. Has the person, principal of the entity, entity, or any entity previously
owned, operated or directed by any of its officers, major shareholders or
directors, within the last five (5) years, been a party to any lawsuit,
arbitration, or mediation with regard to a contract for services, goods or
construction services similar to those requested in the specifications with
private or public entities? If yes, provide details;
d. Has the person, principal of the entity, or any entity previously 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.
8EF 'SYRX]*SVQW
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:
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*SVQW
Submission Response Form
Lobbying and Conflict of Interest Ethics Clause
Non-Collusion Affidavit
Drug Free Workplace Form
Public Entity Crime Statement
Any Proposer claiming a local preference as defined in Monroe County
Ordinance 023-2009 must complete the Local Preference Form and attach to
the Proposal.
'34-)73*6*4(3'91)287
A. Only complete sets of RFP Documents will be issued and shall be used in
preparing responses. The County does not assume any responsibility for errors
or misinterpretations resulting from the use of incomplete sets.
B. Complete sets of RFP Documents may be obtained in the manner and at the
locations stated in the Notice of Request for Proposals.
C. Each Proposer is responsible for obtaining all Addenda for this RFP and for
acknowledging receipt of all Addenda on the Submission Response Form.
78%8)1)283*463437%06)59-6)1)287
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, eight (8) 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
VISION 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 .YRI 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.
(-759%0-*-'%8-323*463437)6
A. NON-COLLUSION AFFIDAVIT: Any person submitting a proposal in response
to this invitation must execute the enclosed NON-COLLUSION AFFIDAVIT. If it
is discovered that collusion exists among the Proposers, the proposals of all
participants in such collusion shall be rejected, and no participants in such
collusion will be considered in future proposals for the same work.
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B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the
convicted vendor list following a conviction for a public entity crime may not
submit a proposal on a contract to provide any goods or services to a public
entity, may not submit a proposal on a contract with a public entity for the
construction or repair of a public building or public work, may not submit
Proposals on leases or perform work as a contractor, supplier, subcontractor,
or contractor under a contract with any public entity, and may not transact
business with any public entity in excess of the threshold amount provided in
Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36
months from the date of being placed on the convicted vendor list. Category
Two: $25,000.00
C. DRUG-FREE WORKPLACE FORM: Any person submitting a bid or proposal
in response to this invitation must execute the enclosed DRUG-FREE
WORKPLACE FORM and submit it with his/her proposal. Failure to complete
this form in every detail and submit it with the bid or proposal may result in
immediate disqualification of the bid or proposal.
D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any person
submitting a bid or proposal in response to this invitation must execute the
enclosed LOBBYING AND CONFLICT OF INTEREST CLAUSE and submit it
with his/her bid or proposal. Failure to complete this form in every detail and
submit it with the bid or proposal may result in immediate disqualification of the
bid or proposal.
)<%1-2%8-323*6*4(3'91)287
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.
+3:)62-2+0%;7%2(6)+90%8-327
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.
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46)4%6%8-323*6)74327)7
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.
13(-*-'%8-323*6)74327)7
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
13(-*-'%8-3283Proposal for Fully Insured Vision BenefitsxIf 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.
6)74327-&-0-8=*366)74327)
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.
6)')-48%2(34)2-2+3*6)74327)7
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
2SXMGISJ6IUYIWXJSV'SQTIXMXMZI7SPMGMXEXMSRMonroe 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.
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.
46346-)8%6=%2('32*-()28-%0-2*361%8-32
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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 requested through a
public records request, the County will notify the Proposer of the request and give the
Proposer five (5) calendar days to obtain a court order blocking the production of the
material. If a court order is not issued during that time to block the production, the
material will be produced.
Please be aware that the designation of an item as exempt from disclosure as a Public
Record may be challenged in court by any person. 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.
%;%6(3*'3286%'8
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.
')68-*-'%8)3*-2796%2')%2(-2796%2')6)59-6)1)287
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
16 of 28
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rating of VI or better, The required insurance shall be maintained at all times while
Proposer is providing service to County.
;SVOIVvW'SQTIRWEXMSR
Statutory Limits
)QTPS]IVWv0MEFMPMX]-RWYVERGI
Bodily Injury by Accident $100,000
Bodily Injury by Disease, policy limits $500,000
Bodily Injury by Disease, each employee $100,000
+IRIVEP0MEFMPMX]MRGPYHMRK
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
$300,000 Combined Single Limit
If split limits are provided, the minimum limits acceptable shall be:
$200,000 per person
$300,000 per occurrence
$200,000 property damage
4VSJIWWMSREP0MEFMPMX] $300,000 per Occurrence
$500,000 Aggregate
Monroe County shall be named as an Additional Insured on the General Liability.
-2()12-*-'%8-32
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.
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In the event that the service is delayed or suspended as a result of the
Proposer/Vendor's failure to purchase or maintain the required insurance, the Vendor
shall indemnify the County from any and all increased expenses resulting from such
delay.
The first ten dollars ($10.00) of remuneration paid to the Proposer is consideration for
the indemnification provided for above. The extent of liability is in no way limited to,
reduced, or lessened by the insurance requirements contained elsewhere within this
agreement.
.)<)'98-323*'3286%'8
The County intends to make an award to the Proposer that has complied with the terms,
conditions and requirements of the RFP. Any agreement resulting from this RFP must
be governed by the laws of the State of Florida, and must have venue established in the
State of Florida. The agreement will be submitted to the Monroe County Board of
County Commissioners for final approval.
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7)'8-328;3 '3928=*3617%2(-2796%2')*3617
?8LMWTEKIMRXIRXMSREPP]PIJXFPERO[MXLJSVQWXSJSPPS[A
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79&1-77-326)74327)*361
RESPOND TO: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
4YVGLEWMRK(ITEVXQIRX
+%83&9-0(-2+6331
7-132832786))8
/)=;)78*036-(%
I acknowledge receipt of Addenda No.(s) _____________
I have included:
Submission 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 licenses and business tax receipts:
______________________________________________________________________
-JXLIETTPMGERXMWRSXERMRHMZMHYEP
WSPITVSTVMIXSV
TPIEWIWYTTP]XLIJSPPS[MRKMRJSVQEXMSR
%440-'%2836+%2->%8-32
:
(Registered business name must appear exactly as it appears on www.sunbiz.org).
%R]ETTPMGERXSXLIVXLERERMRHMZMHYEP
WSPITVSTVMIXSV
QYWXWYFQMXETVMRXSYXSJXLIw(IXEMPF]
)RXMX]2EQIxWGVIIRJVSQ7YRFM^ERHEGST]SJXLIQSWXVIGIRXERRYEPVITSVXJMPIH[MXLXLI
*PSVMHE(ITEVXQIRXSJ7XEXI(MZMWMSRSJ'SVTSVEXMSRW
Fee for services included in contract: $__________________
The fee 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: __________________________ Telephone: ________________
____________________________ Fax: ____________________ Date__________________
Signed: ___________________________ Witness: ________________________
___________________________
(Print Name)
___________________________
(Title)
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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03&&=-2+%2('32*0-'83*-28)6)78'0%97)
7;36278%8)1)2892()636(-2%2')23
13263)'3928=*036-(%
ETHICS CLAUSE
“________________________________________________________________”
(Company)
“…warrants that he/it has not employed, retained or otherwise had act on his/her behalf
any former County officer or employee in violation of Section 2 of Ordinance No. 010-
1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010-
1990. For breach or violation of this provision the County may, in its discretion,
terminate this Agreement without liability and may also, in its discretion, deduct from the
Agreement or purchase price, or otherwise recover, the full amount of any fee,
commission, percentage, gift, or consideration paid to the former County officer or
employee.”
___________________________________
(Signature)
Date: ______________________________
STATE OF: ______________________________
COUNTY OF: ______________________________
Subscribed and sworn to (or affirmed) before me on ___________________________
(date) by _______________________________________ (name of affiant). He/She is
personally known to me or has produced ____________________________________
(type of identification) as identification
____________________________________
NOTARY PUBLIC
My Commission Expires: ______________
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232'30097-32%**-(%:-8
I, _______________________ of the city of _______________________ according to
law on my oath, and under penalty of perjury, depose and say that
1. I 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.
_______________________________
(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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(69+*6));36/40%')*361
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: ______________
23 of 28
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49&0-')28-8='6-1)78%8)1)28
“A person or affiliate who has been placed on the convicted vendor list following a
conviction for public entity crime may not submit a bid on a contract to provide any
goods or services to a public entity, may not submit a bid on a contract with a public
entity for the construction or repair of a public building or public work, may not submit
bids on leases of real property to public entity, may not be awarded or perform work as
a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any
public entity, and may not transact business with any public entity in excess of the
threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO
for a period of 36 months from the date of being placed on the convicted vendor list.”
I have read the above and state that neither ______________________ (Proposer’s
name) nor any Affiliate has been placed on the convicted vendor list within the last 36
months.
________________________________
(Signature)
Date: ___________________________
STATE OF: ______________________________
COUNTY OF: ______________________________
Subscribed and sworn to (or affirmed) before me on ___________________________
(date) by ___________________________(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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13263)'3928=*036-(%
6-7/1%2%+)1)28
430-'=%2(463')(96)7
'3286%'8%(1-2-786%8-321%29%0
-RHIQRMJMGEXMSRERH,SPH,EVQPIWW
*SV
3XLIV'SRXVEGXSVWERH7YFGSRXVEGXSVW
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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;36/)67v'314)27%8-32
-2796%2')6)59-6)1)287
*36'3286%'8&)8;))2
13263)'3928=*036-(%
%2(
CCCCCCCCCCCCCCCCCCCCCCCCCCC
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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+)2)6%00-%&-0-8=
-2796%2')6)59-6)1)287
*36'3286%'8&)8;))2
13263)'3928=*036-(%
%2(
CCCCCCCCCCCCCCCCCCCCCCCCCCC
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.
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463*)77-32%00-%&-0-8=
-2796%2')6)59-6)1)287
*36'3286%'8&)8;))2
13263)'3928=*036-(%
%2(
CCCCCCCCCCCCCCCCCCCCCCCCCCC
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:
$300,000 per occurrence/$500,000 aggregate
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13263)'3928=*036-(%
6-7/1%2%+)1)28
430-'=%2(463')(96)7
'3286%'8%(1-2-786%8-321%29%0
;%-:)63*-2796%2')6)59-6)1)287
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:
8LI'SYRX]EWFIMRKREQIHEWER%HHMXMSREP-RWYVIH – 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
8LI-RHIQRMJMGEXMSRERH,SPH,EVQPIWWTVSZMWMSRW
Waiver 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 6IUYIWXJSV;EMZIVSJ-RWYVERGI
6IUYMVIQIRX 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 proposer may file an appeal
with the County Administrator or the Board of County Commissioners, who retains the
final decision-making authority.
29 of 28
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13263)'3928=*036-(%
6IUYIWX*SV;EMZIV
SJ
-RWYVERGI6IUYMVIQIRXW
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:
CCCCCCCCCCCCCCCCCCCCCCCCCC
463437)67-+2%896)
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LOCAL PREFERENCE FORM
A. Vendors claiming a local preference according to Ordinance 023-2009 must complete this form.
Name of Bidder/Responder______________________________ Date:_______________
1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated at least
one year prior to the notice or request for bid or proposal? __________ (Please furnish copy. )
2. Does the vendor have a physical business address located within Monroe County from which the vendor operates
or performs business on a day to day basis that is a substantial component of the goods or services being offered to
Monroe County?_______________
List Address: ____________________________________________________________
Telephone Number:_______________________________________________________
B. Does the vendor/prime contractor intend to subcontract 50% or more of the goods, services or construction to
local businesses meeting the criteria above as to licensing and location? ____________
If yes, please provide:
1. Copy of Receipt of the business tax paid to the Monroe County Tax Collector by the subcontractor dated at least
one year prior to the notice or request for bid or proposal.
2. Subcontractor Address within Monroe County from which the subcontractor operates:
__________________________________________ Tel. Number _____________________
_________________________________________ Print Name:______________________
Signature and Title of Authorized Signatory for
Bidder/Responder
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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ʹͲͳ
)\LMFMX%7GSTISJ7IVZMGIW
8LI4VSTSWIV[MPPFIIZEPYEXIHSRGSQTPMERGI[MXLXLIFIPS[WIVZMGI
VIUYMVIQIRXW&]WYFQMXXMRKETVSTSWEPXLI4VSTSWIVEKVIIWXLEXXLIWI
TVSZMWMSRW[MPPFITEVXSJXLIEKVIIQIRXFIX[IIRXLITEVXMIW
(IPMZIVEFPIW -JRIGIWWEV]XLI4VSTSWIVWLEPPTVSZMHIETSPMG]%QIRHQIRX
)RHSVWIQIRXSV6MHIVXSXLI'SYRX]XSEGGSQQSHEXIRSRWXERHEVHTSPMG]
TVSZMWMSRWEKVIIHXSF]XLI4VSTSWIV
=IW'ER'SQTP]FYX[MXL
=IW2S
7TIGMJMIH(IZMEXMSRW
7IVZMGI6IUYMVIQIRX'ER'ERRSX
TPIEWIHIXEMPHIZMEXMSRW
'SQTP]'SQTP]
FIPS[
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.
The Proposer shall maintain
compliance with all federal,
state, and local laws,
ordinances, rules,
professional license
requirements and
regulations that in any
manner affect the work.
Provide firm rates for the
effective date of the policy
based on the information
provided in the RFP.
Variations in actual enrollment
shall have no effect on the rate
proposal. The proposal shall be
valid regardless of the final
enrollment mix, number of
Proposers, number of plan
designs or outcome.
All charges for any service
or optional service must be
clearly outlined in the
pricing Attachment.
1
4EGOIX4K
'F
ʹͲͳ
)\LMFMX%7GSTISJ7IVZMGIW
=IW'ER'SQTP]FYX[MXL
=IW2S
7TIGMJMIH(IZMEXMSRW
7IVZMGI6IUYMVIQIRX'ER'ERRSX
TPIEWIHIXEMPHIZMEXMSRW
'SQTP]'SQTP]
FIPS[
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.
The successful Proposer
must provide an Account
Manager responsible for
the overall relationship.
The successful Proposer
must participate in open
enrollment meetings on an
annual basis.
Provide estimated
renewal rates 120 days in
advance of renewal.
Produce all appropriate
materials, including but
not limited to: enrollment
materials, certificates of
coverage & schedules of
benefits, summary of
benefits, provider lists, etc.
The County shall review
and approve all open
enrollment communication
materials prior to release
to employees.
Provide standard reports to the
County on a quarterly basis and
provide ad hoc reports, upon
request.
2
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Provide performance
guarantees with financial
penalties for non-
performance. Performance
guarantees should include:
Maintaining Network
Access
Claim turnaround
time
Claim payment
accuracy
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
COUNTY.
The COUNTY may terminate
this Agreement with or
without cause upon thirty
Proposer. COUNTY shall
pay Proposer for work
performed through the date
of termination.
Pursuant to Florida Statute
§119.0701, Proposer and its
subcontractors shall comply
with all public records laws of
the State of Florida, specifically
3
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to:
(a)Keep and maintain
public records that ordinarily
and necessarily would be
required by Monroe County in
the performance of this
Agreement;
(b) Provide the public
with access to public records on
the same terms and conditions
that Monroe County would
provide the records and at a
cost that does not exceed the
cost provided in Florida
Statutes, Chapter 119 or as
otherwise provided by law;
(c) Ensure that public
records that are exempt or
confidential and exempt from
public records disclosure
requirements are not disclosed
except as authorized by law;
(d)Meet all requirements
for retaining public records and
transfer, at no cost, to Monroe
County all public records in
possession of the Proposer
upon termination of this
Agreement and destroy any
duplicate public records that are
exempt or confidential and
exempt from public records
disclosure requirements. All
records stored electronically
must be provided to Monroe
County in a format that is
compatible with the information
technology systems of Monroe
County; and
(e) Upon completion of the
contract, transfer, at no cost, to
the County all public records in
possession of the Contractor or
keep and maintain public
records that would be required
by the County to perform the
service. If the Contractor
4
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transfers all public records to
the County upon completion of
the contract, the Contractor
shall destroy any duplicate
public records that are exempt
or confidential and exempt from
public records disclosure
requirements. If the Contractor
keeps and maintains public
records upon completion of the
contract, the Contractor shall
meet all applicable
requirements for retaining
public records. All records
stored electronically must be
provided to the County, upon
custodian of records, in a
format that is compatible with
the information technology
systems of the 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, at
fees, or liability of any kind
arising out of the sole negligent
actions of the Proposer or
substantial and unnecessary
delay caused by the willful
nonperformance of the
Proposer and shall be solely
responsible and answerable for
any and all accidents or injuries
to persons or property arising
out of its performance of this
contract. The amount and type
of insurance coverage
5
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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.
6
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1What is the legal name of your company or corporation?0
2In what state is your company’s corporation domiciled?0
3In what state is your company’s home office?0
4In what year was your: Corporation founded?0
Company founded? (If different than corporation)
5What is the structure of your company, Corporation, LLC 0
etc.?
6Is your Vision Insurance Company a division or subsidiary Yes___75
of another company or corporation?No ____
If yes, please provide information on your corporate owner.
0
0
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7Is your company offering its group voluntary vision Yes ____ 65
insurance coverage through a trust licensed or registered No____
outside the State of Florida?If yes, please provide information on the Trust.
8In how many states is your company licensed to conduct 0
business as a group vision insurance company?
9Is your company currently licensed in the State of Florida Yes_______197
to conduct business as a group voluntary vision insurance No_______
company?If no, please provide what type of licensing or registration your company has to conduct business as a
voluntary vision insurance company or provider in the State of Florida.
10How many years has your company been offering group 0
voluntary vision insurance plans in the State of Florida?
11Is your company rated by A.M. Best?Yes______146
No______
If yes, please provide your company’s A.M. Best rating - include the Letter rating and Size category.
Current:
2014:
2013:
12If your company does not have an A.M. Best rating, Agency Name: 69
please provide the latest financial rating of your Current:
organization from any two (2) of the recognized financial 2014:
rating companies or agencies for the years requested in 2013:
question 11.
Agency Name:
Current:
2014:
2013:
0
1The Monroe County Board of Commissioner is requesting Yes ____17
that each proposer match as closely as possible the No ____
current VSP benefits as provided in the current VSP Plan.
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2What, if any benefit limitations or deviations does your 0
company have in relation to the requested RFP group
voluntary vision plan benefits? Please provide a listing of
all deviations in Tab 6.
0
0
3Does your company offer plan portability for employees Yes_______141
who wish to retain their voluntary vision program coverage No _______
at time of employment termination? If yes, please provide a detailed description of the plans available and the respective premium for
the plan.
0
0
4Is your company willing to offer a multi-year rate Yes__________102
guarantee on the voluntary vision program provided in No_____________
your proposal? If yes, please explain what type of guarantees and for what time period.
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5Is your contract cancelable for any reason other than non-Yes __________ 81
payment of premium?No ______________
If yes, please provide reason for cancellation.
0
0
6Does your company underwrite any of the risk of your Yes______146
vision plan? No_______
If no, please provide information as to how your company lays off the risk and the reinsurance company
that handles this risk.
0
0
7If your company does underwrite the risk of your products, 0
please provide information as to how that risk is handled?
i.e., total risk assumption, reinsured
0
0
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8Does your company provide a free breakage warranty?Yes______72
No _______
If yes, how long does the breakage warranty last?
9Does your company offer an enhanced frame allowance?Yes_____No ______66
If yes, please provide your company’s program.
0
0
0
10The County will need enrollment assistance in each year 0
for the annual open enrollment. If you cannot commit to
supplying trained staff in the Florida Keys for meetings
that will take place over seven (7) business days, please
indicate the level of support that you can provide for Open
Enrollment.
0
0
1The Monroe County Board of Commissioners requests to Yes _________28
be self billed and will remit premium payments 45 days No_________
after the due date.
2If your company is selected to offer the voluntary vision Yes________108
plan at the Monroe County Board of Commissioners, will No_________
your company accept an electronic transfer of enrollment If yes, please indicate the required format for transmission of eligibility data.
and eligibility information in lieu of enrollment forms?
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0
0
0
3Please explain how your company audits the monthly 0
eligibility and reconciles each month's billing.
0
0
1Where will the Monroe County Board of Commissioner’s 0
Voluntary Vision Plan claims be processed?
2Is this location a national or regional claims facility? National__________42
Regional ____________
3Does your company own and operate the claims facility, or 0
do they contract these services through a TPA or other
third party arrangement?
4What are the days and hours of your claims office 0
operations?
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5Please identify the holidays in which your claims office is 0
closed.
6How many claims processors are employed at your claims 0
facility?
7What is the average tenure of your claims personnel?0
8In addition to English, please indicate what languages a. Spanish:111
your claims office has available to the County’s members.b. French:
c. Creole:
d. Vietnamese:
e. Other:
9Does your company use home based claims Yes _______188
representatives?No _________
If yes, how long has your company been utilizing home based claims representatives, and what
percentages of your claims representatives are home based employees?
0
0
10How many claims are processed through this facility 0
annually?
11What is the average turnaround time for a clean claim?0
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12What percentage of claims are auto adjudicated?0
13Does your company have an audit process that monitors Yes_______115
the accuracy of the claims that are paid?No________
If yes, please provide the accuracy standards of your claims office and the results for 2015.
14Does your company offer claims submission online?Yes_________97
No __________
If yes, please provide details of this service and the access address
0
0
15Does your company offer claims viewing online? Yes _________100
No___________
If yes, please provide details of this service and the access address.
0
0
16Does your claims office have a toll free “800” number Yes __________74
access for employer and member use? No _____________
If yes, please provide the “800” number.
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17Please describe the security protection your company has 0
established for your claims office. Provide information on
access authorizations and the handling and storage of
sensitive information.
0
0
18Does your company have any plans to relocate the claims Yes_________63
operation within the next 36 months?No____________
If yes, please provide the details.
0
0
19Does your company plan on downsizing the claims office Yes___________62
staff within the next 36 months? No_________
If yes, please provide the details.
0
0
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20Does your company have plans to upgrade or change the Yes ________ 62
software/hardware of the claims computer system within No_________
the next 36 months? If yes, please provide the details.
0
0
21In the past 12 months, has your claims system gone Yes _________ 80
down, failed or was unable to process claims correctly or No __________
in a timely manner?If yes, please provide details of the incident(s).
0
0
0
1What type of vision providers does your company offer in a. Independent Optometrists: 109
Florida Keys?b. Independent Ophthalmologists:
c. Retail Optometrists:
d. All of the above
2Does your company own or lease the vision network?Own:110
Lease:
If your company leases the network, please provide information concerning the network company.
3Does your company offer network vision provider Yes________26
information online?No _________
4If yes, can the provider information be accessed for:0
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a. Total network listing of Optometrists? Yes _______21
No_______
b. Total network listing of Ophthalmologists? Yes _______21
No_______
c. Total network listing of retail outlets?Yes _______21
No_______
d. Search by vision provider’s specialty?Yes _______21
No_______
e. Search by vision provider’s zip code? Yes _______21
No_______
f. Can the vision providers’ information be Yes _______21
downloaded and printed? No_______
5Does your company provide hard copy network directories Yes _______21
to its members?No_______
6Does your provider directory list the following information 0
for vision providers?
a. Office address and telephone number:Yes _______21
No_______
b. Multiple office locations:Yes _______21
No_______
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c. Specialty:Yes _______21
No_______
d. The vision providers office hours: Yes _______21
No_______
e. Number of years in practice:Yes _______21
No_______
f. Medical degree(s):Yes _______21
No_______
g. Languages spoken by the vision providers and Yes _______21
staff:No_______
7Are providers required to maintain professional liability Yes _______21
coverage?No_______
In what amount? (Please clarify specific to per occurrence
or aggregate limits.)
8Describe how your organization communicates with and 0
supports its providers.
9Please provide the number of network vision providers 0
your company has in Florida Keys for the Cities listed .
Number of OptometristsKey Largo:62
Marathon:
Big Pine Key:
Summerland Key:
Key West:
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Number of OpthalmologistsKey Largo:62
Marathon:
Big Pine Key:
Summerland Key:
Key West:
Number of Opticians/Dispensing LocationsKey Largo:62
Marathon:
Big Pine Key:
Summerland Key:
Key West:
10Please list the names of the retail outlets and the number Name of Retail Store/ Number of Outlets41
of stores in Monroe County (only).
11Are all listed network providers full-service (i.e., provide Yes ____16
both exams and dispense eyewear at their listed No ____
location)?
12Provide an electronic list (on a flash drive or CD, in a Please provide this listing under Tab 6 of your Response.57
usable Excel format) of your most up-to-date provider
directory for Monroe County - only. Please provide
individual participating providers by name, even if they
have the same TIN. The required format for the list
follows:
Last Name| First Name| Middle Initial | Street Address |
Suite Number | City| Zip Code| Specialty| Network
Designation.
13Please provide the GeoAccess Reports under Tab 6 of your Response.66
Complete the following GeoAccess summary for the
County’s employees. Your study should include a
summary report for each of the items listed below. Each
summary should indicate the total number and percentage
of employees with access by zip code and by for all
networks that you are proposing. Please include
GeoAccess Reports.
a. Number and percentage of employees with two
Optometrists within ten miles of the employee’s zip code.
b. Number and percentage of employees with two
Opthalmologists within ten miles of the employee’s zip
code.
c. Number and percentage of employees with two
dispensing facilities / Opticians within ten miles of the
employee’s zip code.
14Do you provide members with an internet based option for Yes ____18
purchasing lenses, frames, and/or contacts?No ____
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15If you responded yes to the question above regarding 0
online purchasing, please explain your program briefly,
including any additional costs for the program.
0
0
0
1Where is the location of your member service office that 0
will be servicing the Monroe County Board of
Commissioners participants?
2Is this a national or regional member service office?National _______ 34
Regional ______
3Does your company own and maintain the member Yes ____39
service unit?No ____
If no, please explain.
4Is this the same location as the claims office?Yes_________27
No _________
5How many member service employees are in this office?0
6What is the average tenure of your member service 0
representatives?
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7What are the days and hours of operation?0
8Please identify the holidays in which your member service 0
office is closed.
9Does your company staff their member service Yes________27
department with individuals who know and understand No__________
voluntary vision contracts, benefits and procedures and
are able to assist County members without having to call
the member back?
10In addition to English, please indicate what languages a. Spanish: 101
your member services has available to the County’s b. French:
members.c. Creole:
d. Vietnamese:
e. Other:
11Does your company use home based member service Yes_________27
representatives that report to this location?No _________
12If you answered yes to the use of home based member 0
service representatives, 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?
0
0
13Does the member service office have a toll free “800” Yes________24
number for employer and member access?No________
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14If you use home based member service representatives, Yes________24
does the toll free member services phine number No________
automatically route to these representatives?
15Does your company monitor and tape member services Yes________24
calls?No________
16Can your member service unit be accessed by the Monroe Yes_________90
County Board of Commissioner members online? No _________
What services are provided online? If yes, please provide details of your website and its address.
0
0
17Does the member service office monitor and keep records Yes________24
on the number and type of service calls it receives?No________
18Please provide the current telephone performance Number of calls per day:94
statistics of your company’s member service unit in regard Average length of call:
to:% of abandoned calls:
Average hold time:
19In the past 12 months, has your member service unit or Yes _______73
phone system gone down, failed or was unable to meet No________
the demands of the members?If yes, please provide details of the incident(s).
0
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0
20Does your company have any plans within the next 36 Yes_________57
months to move or relocate the member service unit?No_________
If yes, please provide details.
0
0
21Does your company plan within the next 36 months to Yes_________57
upgrade or change the computer system your member No_________
service unit is currently using?If yes, please provide details.
0
0
0
1The Monroe County Board of Commissioner is requesting Yes _______85
a utilization reporting package in this RFP. Is your No________
company willing to provide a utilization reporting package If yes, please provide samples of the claims reports in TAB 6.
to the County for the group voluntary vision program you
have responded to in this RFP?
2Are the utilization reports included in your premium Yes________76
pricing?No________
If no, please detail concerning the additional cost.
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3What frequency will your company provide the utilization Monthly:69
reporting?Quarterly:
Semi annually:
Annually:
0
1Please provide additional information on your company 0
that you feel will differentiate you from the competition in
providing quality and affordable voluntary vision coverage.
0
2Please detail the performance standards you are willing to
guarantee and the amount of money you are willing to put
at risk for at least the following:
Claim Turnaround Time
Claim Payment Accuracy
Network Provider Access
If you are able to provide guarantees for additional
performance metrics, please include them here. All
guarantees will be considered.
0
Low Option Plan
1
Employee Only
Employee + Spouse
Employee + Child/Children
Employee + Family
Additional Cost for Enhancements - factor to
be added to the Low Option Plan Rate for Each Item.
2
12 month Frame Replacement
UV Coating included in Prescription
Standard Polycarbonate at $10 Copayment
Anti Reflective Coating at $40
Premium Progressive Lenses at $55
Frame Allowance (in network) $180
Elective Contact Allowance in Lieu of Lenses &
Frames $130
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High Option Plan - Proposed Rates for Complete High
Option Plan
3
Employee Only
Employee + Spouse
Employee + Child/Children
Employee + Family
4Rate Guarantees: please indicate the length of time in
months or years and the period of the guarantee as a date
range.
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13263)'3928=&3%6(3*'3928='311-77-32)67
*900=-2796)(:-7-326*4
)<,-&-8'&)2)*-83**)6-2+
Vendor NameVendor Name
'%8)+36=
'YVVIRX4PER4VSTSWIH0S[3TXMSR4PER4VSTSWIH,MKL3TXMSR4PER
)<%17-R2IX[SVO3YXSJ2IX[SVO-R2IX[SVO3YXSJ2IX[SVO-R2IX[SVO3YXSJ2IX[SVO
%PPS[ERGI%PPS[ERGI%PPS[ERGI
Regular Exam with Dilation as Needed$10 Copay$45
Contact Lens exam (fitting and evaluation)
SJJ6IXEMP2%
9TXSGSTE]QIRX
$20Allowance Provided
1EXIVMEPW
'STE]QIRXETTPMIWSRIXMQI
[MXLFIRIJMX
Frames at any available provider locationCovered up to $70
allowance
$140 allowance
20% Discount on
balance over $140
STANDARD LENSES
Single VisionCovered in Full after $20 $30
Copay
BifocalCovered in Full after $20 $50
Copay
TrifocalCovered in Full after $20 $65
Copay
LENS OPTIONS
UV CoatingAdditional CostN/A
Standard Scratch-resistanceAdditional CostN/A
Standard PolycarbonateIncluded for Dependent N/A
Children Additional Cost
Anti-reflective coatingAdditional CostN/A
Standard Progressive $55Up to $50
Premium Progressive$95 - $105Up to $50
Custom Progressive$150 - $175Up to $50
Photocromic LensesAdditional CostN/A
Other Add-ons and servicesAverage 20% off RetailN/A
CONTACT LENSES
Conventional$115 Allowance$105
In lieu of Lenses and
Frames
Disposable$115 Allowance$105
In lieu of Lenses and
Frames
Medically necessaryPaid in full after $210 Allowance less
Necessary Contact Lenses are a Plan Applicable copaysCopyament
Benefit when specific benefit criteria are
satisfied and when prescribed by Covered
Person's VSP Network
Doctor or Non-VSP Provider. Prior review
and approval by VSP are not required for
Covered Person to be eligible for
Necessary Contact Lenses.
Frequency LimitsExam every 12 monthsExam every 12 monthsExam every 12 months
Lenses every 12 monthsLenses every 12 monthsLenses every 12 months
Frames every 24 monthsFrames every 24 monthsFrames every 12 months
4EGOIX4K
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October 31, 2013
Vision Care for Life
MARY KAY LANTZ
GALLAGHER BENEFIT SERVICES, INC
2255 GLADES RD STE 400E
BOCA RATON, FL 33431-7379
RE: NOTIFICATION OF DOCUMENT CHANGES FOR MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Enclosed are the new VSP Plan document and Evidence of Coverage booklet for the above-referenced group, both effective JANUARY 1, 2014.
Please also be advised if your clien
Statute 627.6562 which impacts health insurance contracts that provide coverage for dependent children. The Statute requires dependent children to
be covered until the end of the calendar year in which they reach age 25.
This new document supersedes any existing document your client has with VSP. If you or your client have any questions concerning the new
document, please call 866-213-2249, and a VSP representative will assist you. Please retain a copy for your records and forward the additional copy
directly to the client.
Enclosures
7KHVHGRFXPHQWVDUHLQWHQGHGRQO\IRUWKHFOLHQWWRZKRPWKH\DUHDGGUHVVHGDQGPD\FRQWDLQFRQILGHQWLDOLQIRUPDWLRQ,I\RXDUHQRWWKHLQWHQGHGUHFLSLHQW RUWKHSHUVRQUHVSRQVLEOHIRU
GHOLYHULQJLWWRWKHLQWHQGHGUHFLSLHQW
DQGKDYHUHFHLYHGWKHVHGRFXPHQWVLQHUURUSOHDVHQRWLI\WKHVHQGHULPPHGLDWHO\E\WHOHSKRQHDQGGHVWUR\RUGHOHWHWKHVHGRFXPHQWV
4EGOIX4K
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Vision Care for Life
VISION SERVICE PLAN INSURANCE COMPANY
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE POLICY
Group Name MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Policy Number 30029497
State of Delivery FLORIDA
Effective Date JANUARY 1, 2014
Policy Term THIRTY-SIX (36) MONTHS
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by the Group of the premiums as herein provided, VISION SERVICE PLAN INSURANCE COMPANY ("VSP")
agrees to insure certain individuals under this Group Vision Care Policy ("Policy") for the benefits provided herein,
subject to the exceptions, limitations and exclusions hereinafter set forth. This Policy is delivered in and governed by
the laws of the state of delivery and is subject to the terms and conditions recited on the subsequent pages hereof,
including any Exhibits or state-specific Addenda, which are a part of this Policy..
____________________________________________
James M. McGrann, Secretary
VSP GVCP FL 1004. DDM 10/31/13 Kav
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VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
TABLE OF CONTENTS
I. DEFINITIONS.............................................................................................................. 1
II. TERM, TERMINATION, AND RENEWAL................................................................... 3
III. OBLIGATIONS OF VSP.............................................................................................. 4
IV. OBLIGATIONS OF THE GROUP................................................................................ 7
V. OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY............................. 9
VI. ELIGIBILITY FOR COVERAGE................................................................................... 12
VII. CONTINUATION OF COVERAGE.............................................................................. 14
VIII. ARBITRATION OF DISPUTES.................................................................................... 15
IX. NOTICES..................................................................................................................... 16
X. MISCELLANEOUS...................................................................................................... 17
EXHIBIT A
SCHEDULE OF BENEFITS........................................................................... 19
EXHIBIT B
SCHEDULE OF PREMIUMS......................................................................... 26
EXHIBIT C
ADDITIONAL BENEFIT - DIABETIC EYECARE........................................... 27
ADDENDUM
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'I
VISION SERVICE PLAN INSURANCE COMPANY
GROUP VISION CARE POLICY
I.
DEFINITIONS
The key terms in this Policy are defined:
1.01. ADDITIONAL BENEFIT RIDER: The document, attached as Exhibit C to this Policy (if purchased by
Group), which lists selected vision care services and vision care materials which a Covered Person is entitled to receive
under this Policy. Additional Benefits are only available when purchased by Group in conjunction with a Plan Benefit offered
under Exhibit A.
1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan whereby Group pays VSP for the
Plan Benefits in addition to a monthly administrative fee.
1.03. BENEFIT AUTHORIZATION: Authorization from VSP identifying the individual named as a Covered
Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled.
1.04. CONFIDENTIAL MATTER: All confidential information concerning the medical, personal, financial or
business affairs of Covered Persons acquired in the course of providing Plan Benefits hereunder.
1.05. COORDINATION OF BENEFITS: Procedure which allows more than one insurance plan to consider
1.06. COPAYMENTS: Those amounts required to be paid by or on behalf of a Covered Person for Plan
Benefits which are not fully covered, and which are payable at the time services are rendered or materials provided.
1.07. COVERED PERSON: An Enrollee or Eligible Dependent who meets Group's eligibility criteria and on
whose behalf premiums have been paid to VSP, and who is covered under this Policy.
1.08. ELIGIBLE DEPENDENT: Any dependent of an Enrollee of Group who meets the criteria for eligibility
established by Group
1.09. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the
Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non-medical action.
1.10. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under VI.
ELIGIBILITY FOR COVERAGE.
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1.11. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care
profession, as determined by VSP.
1.12. EVIDENCE OF COVERAGE: A summary of the Policy provisions, prepared by VSP and provided to
Group for distribution to Enrollee.
1.13. GROUP: An employer or other entity which contracts with VSP for coverage under this Policy in order to
provide vision care coverage to its Enrollees and their Eligible Dependents.
1.14. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP.
1.15. GROUP VISION CARE Policy (also, "The Policy"): The Policy issued by VSP to a Group, under which
its Enrollees or members, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan
Benefits in accordance with the terms of such Policy.
1.16. VSP NETWORK DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice
vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision
care materials on behalf of Covered Persons of VSP.
1.17. NON-VSP PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified vision
care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered
Persons of VSP.
1.18. PLAN or PLAN BENEFITS: The vision care services and vision care materials which a Covered Person
is entitled to receive by virtue of coverage under this Policy, as defined in the Schedule of Benefits (Exhibit A) and, if
purchased by Group, the Additional Benefit Rider (Exhibit C), attached hereto.
1.19. RENEWAL DATE: The date when the Policy shall renew, or terminate if proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached as Exhibit A to this Policy, which lists the vision
care services and vision care materials which a Covered Person is entitled to receive under this Policy.
1.21. SCHEDULE OF PREMIUMS: The document, attached hereto as Exhibit B, which states the payments to
be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.
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II.
TERM, TERMINATION, AND RENEWAL
2.01. This Policy is effective on the Effective Date and shall remain in effect for the Policy Term. At the end of the
Policy Term, the Policy shall renew on a month to month basis unless either party notifies the other in writing, at least ninety
(90) days before the end of the Policy Term, that such party is unwilling to renew the Policy If such notice is given, the
Policy shall terminate at 11:59 p.m. in the state of delivery on the last day of the Policy Term unless the parties agree on its
renewal of the Policy. If the Policy continues on a month to month basis after the Policy Term, either party may terminate
the Policy upon thirty (30) days advance written notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Policy Term and
Group fails to accept the new terms and/or rates in writing prior to the end of the Policy Term, this Policy shall terminate at
11:59 p.m. on the last day of the Policy Term.
2.02. Early Termination Provision: The premium rate payable by Group under this Policy is based on an
assumption that VSP will receive these amounts over the full Policy Term in order to cover costs associated with greater
vision utilization that tends to occur during the first portion of a Policy Term. If Group terminates this Policy before the end of
the Policy Term or before the end of any subsequent renewal terms, for any reason other than material breach by VSP, then
Group will remain liable to VSP for the lesser amount of any deficit incurred by VSP or the payments which Group would
have paid for the remaining term of this Policy, not to exceed one year. A deficit incurred by VSP will be calculated by
subtracting the cost of incurred and outstanding claims, as calculated on an incurred date basis with a claim run-out not to
exceed six months from the date of termination, from the net premiums received by VSP from Group. Net premiums shall
mean premiums paid by Group minus any applicable retention amounts and/or broker commissions Group agrees to pay
VSP within thirty-one (31) days of notification of the amount due. VSP shall return any unearned premiums to Group upon
termination.
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III.
OBLIGATIONS OF VSP
3.01. Coverage of Insureds: VSP will enroll for coverage each eligible Enrollee and his/her Eligible
Dependents, if dependent coverage is provided, all of whom shall be referred to upon enrollment as "Covered Persons." To
institute coverage, VSP may require Group to complete, sign and forward to VSP a Group Application along with information
regarding Enrollees and Eligible Dependents, and all applicable premiums. (Refer to VI. ELIGIBILITY FOR COVERAGE for
further details.)
Following the enrollment of the Covered Persons, VSP will provide Group with Member Benefit Summaries and a
copy of the Evidence of Coverage, with Exhibits, for distribution to Covered Persons. Such Member Benefit Summaries and
Evidence of Coverage will summarize the terms and conditions set forth in this Policy.
3.02. Provision of Plan Benefits: Through its VSP Network Doctors (or through other licensed vision care
providers where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-VSP Provider), VSP
shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits (Exhibit A) or, when purchased by
Group, Additional Benefit Rider (Schedule C) attached hereto, subject to any limitations, exclusions, or Copayments therein
stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a VSP Network
Doctor. When a Covered Person seeks Plan Benefits from a VSP Network Doctor, the Covered Person must schedule an
appointment and identify himself as a VSP Covered Person, so the VSP Network Doctor can obtain Benefit Authorization
from VSP. VSP shall provide Benefit Authorization to the VSP Network Doctor to authorize the provision of Plan Benefits to
the Covered Person. Each Benefit Authorization will contain an expiration date, stating a specific time period for the
Covered Person to obtain Plan Benefits.
VSP shall issue Benefit Authorizations in accordance with the latest eligibility information furnished by Group and the
uthorization so issued by VSP shall constitute a certification
to the VSP Network Doctor that payment will be made, irrespective of a later loss of eligibility of the Covered Person,
provided Plan Benefits are received prior to the Benefit Authorization expiration date.
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VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, but not more
than thirty (30) calendar days after VSP has received a completed claim, unless special circumstances require additional
time. If VSP requires additional information in order to pay or deny all or any portion of a claim, VSP will notify the person
submitting the claim within forty-five (45) days after the receipt of the claim. Upon receipt of the requested information, VSP
will pay or deny the claim within sixty (60) days. All claims shall be paid or denied by VSP within one hundred twenty (120)
days after receipt of claim.
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-VSP PROVIDERS ARE USED.
When Covered Persons elect to utilize the services of a Non-VSP Provider for a covered service in non-emergency
situations, benefit payments for services from such Non-VSP Provider are not based upon the amount billed. The basis of
the benefit payment will be determ-VSP Provider fee schedule. COVERED PERSONS
CAN EXPECT TO BE LIABLE FOR MORE THAN THE COPAYMENT AMOUNT DEFINED IN THE ATTACHED
SCHEDULE OF BENEFITS OR ADDITIONAL BENEFITS RIDER (when purchased by Group) AFTER THE PLAN HAS
PAID ITS REQUIRED PORTION.
When payment is made to the Non-VSP Provider, the provider may bill Covered Persons for any amount up to the
billed charges after the Plan has paid its portion of the bill. VSP Network Doctors have agreed to accept discounted
payments for services with no additional billing to the Covered Person other than Copayments, co-insurance and any
amounts for non-covered services and/or materials. Covered Persons may obtain further information about the participating
status of providers and information on out-of-
Department at 1-800-877-7195.
3.03. Provision of Information to Covered Persons: Upon request, VSP shall make available to Covered
Persons necessary information describing Plan Benefits and how to use them. A copy of this Policy shall be placed with
Group and also will be made available at the offices of VSP for any Covered Persons. VSP shall provide Group with an
updated list of VSP Network Doctors' names, addresses, and telephone numbers for distribution to Covered Persons twice
-free telephone line, or by written request.
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3.04. Preservation of Confidentiality: VSP shall hold in strict confidence all Confidential Matters and exercise
its best efforts to prevent any of its employees, VSP Network Doctors, or agents, from disclosing any Confidential Matter,
except to the extent that such disclosure is necessary to enable any of the above to perform their obligations under this
Policy, or to comply with applicable law. Covered Persons and
Service Department.
3.05. Emergency Vision Care: When vision care is necessary for Emergency Conditions, Covered Persons
may obtain Plan Benefits by contacting a VSP Network Doctor or Non-VSP Provider. No prior approval from VSP is required
for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical
conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare
Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' medical insurance plan for care. For emergency conditions of a
non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
Department for assistance. Reimbursement and eligibility are subject to the terms of this Policy.
3.06 Coordination of Benefits: When VSP is primary, it will pay benefits according to the terms of the
Policy, subject to any applicable state or federal codes, statutes or regulations. When VSP is secondary, it will coordinate
lesser of:
a) The normal Plan Benefit, in the absence of other coverage, or
b) The remainin
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IV.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under this Policy if he/she
satisfies the enrollment criteria specified in Paragraph 6.01(a) and as established by Group. By the Effective Date of this
Policy, Group shall provide VSP with eligibility information, in a mutually agreed upon format and medium, to identify all
Enrollees who are eligible for coverage under this Policy as of that date. Thereafter, Group shall supply to VSP by the 15th
day of each month, eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage
rosters. All additions and deletions shall become effective on the first day of the month specified by Group. The eligibility
request, Group shall make available for inspection records regarding the coverage of Covered Persons under this Policy.
4.02. Payment of Premiums: By the first day of each month, Group shall remit to VSP the premiums payable
for the next month on behalf of each Enrollee and Eligible Dependents, if any, to be covered under this Policy. The
Schedule of Premiums incorporated in this Policy as Exhibit B provides the premium amount for each Covered Person. Only
Covered Persons for whom premiums are actually received by VSP shall be entitled to Plan Benefits under this Policy and
only for the period for which such payment is received, subject to the grace period provision below.
VSP may change the premiums set forth in Exhibit B (Schedule of Premiums) by giving Group at least hundred
twenty (120) days advance written notice. No change will be made during the Policy Term unless there is a change in the
Schedule of Benefits and/or Additional Benefits Rider (if purchased by Group), or there is a material change in Policy terms
or conditions, provided any such change is mutually agreed upon in writing by VSP and Group.
Notwithstanding the above, VSP may increase premiums during a Policy Term by the amount of any tax or assessment not
now in effect but subsequently levied by any taxing authority, which is attributable to premiums VSP received from Group.
4.03. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the premium
payment due date to pay premiums due under this Policy. During said grace period, this Policy shall remain in full force and
effect for all Covered Persons of Group. VSP will consider late payments at the time of Policy renewal. Such payment may
in future Policy Terms.
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If Group fails to make any premiums payment due by the end of any grace period, VSP may notify Group that the
premiums payment has not been made, that coverage is canceled and that Group is responsible for payment for all Plan
Benefits provided to Covered Persons after the last period for which premiums were paid in full, including the grace period
through the effective date of termination. Group shall also be responsible for any legal and/or collection fees incurred by
VSP to collect amounts due under this Policy.
4.04. Distribution of Required Documents: Group shall distribute to Enrollees any disclosure forms, Policy
summaries or other material required to be given to Policy subscribers by any regulatory authority. Such materials shall be
distributed by Group no later than thirty (30) days after the receipt thereof, or as required under applicable law.
4.05. Converting to an Administrative Services Program: Due to the cyclical nature of vision care, in the
event Group wishes to convert its method of funding from a risk program to an Administrative Services Program, an
appropriate level of reserve will need to have been established.
Upon conversion to an Administrative Services Program, for vision care begun on and after the effective date of
conversion, all claims will be paid through the Administrative Services Program.
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V.
OBLIGATIONS OF COVERED PERSONS UNDER THE POLICY
5.01. General: By this Policy, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided. However, this Policy may be amended or terminated by agreement between VSP and
Group as indicated herein, without the consent or concurrence of Covered Persons. This Policy, and all Exhibits, Riders and
attachments hereto, constitute VSP's sole and entire undertaking to Covered Persons under this Policy.
As conditions of coverage, all Covered Persons under this Policy have the following obligations:
5.02. Copayments for Services Received: Where, as indicated in Exhibit A (Schedule of Benefits) and Exhibit
C (Additional Benefit Rider) when purchased by Group, Copayments are required for certain Plan Benefits. Copayments
shall be the personal responsibility of the Covered Person receiving the care and must be paid at the time services are
rendered. Amounts that exceed Plan allowances, annual maximum benefits, options reimbursements, or any other stated
Plan limitations are not considered Copayments but are also the responsibility of the Covered Person.
5.03. Obtaining Services from VSP Network Doctors: Benefit Authorization must be obtained prior to
receiving Plan Benefits from a VSP Network Doctor. When a Covered Person seeks Plan Benefits, the Covered Person
must select a VSP Network Doctor, schedule an appointment, and identify himself as a Covered Person so the VSP
Network Doctor can obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a VSP
Network Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered
Person, the VSP Network Doctor will be considered a Non-VSP Provider, and the benefits available will be limited to those
for a Non-VSP Provider, if any.
5.04. Submission of Non-VSP Provider Claims: If Non-VSP Provider coverage is indicated in Exhibit A
(Schedule of Benefits) or Exhibit C (Additional Benefit Rider), when purchased by Group, written proof (receipt and the
-VSP Providers shall be submitted
by Covered Persons to VSP within three hundred sixty-five (365) days of the date of service. VSP may reject such claims
filed more than three hundred sixty-five (365) days after the date of service.
Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not
reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as reasonably
possible and in no event, except in absence of legal capacity, later than one year from the required date of three hundred
sixty-five (365) days after the date of service.
5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at
the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care,
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treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may
submit written comments or supporting docu
VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an
extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty
thirty (30) days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify the
Covered Person of the outcome in writing.
5.06. Claim Denial Appeals: If, under the terms of this Policy, a claim is denied in whole or in part, a request
may be submitted to VSP by Covered Person, or Covered Person's authorized representative, for a full review of the denial.
Covered Person may designate any person, including their provider, as their authorized representative. References in this
section to "Covered Person" include Covered Person's authorized representative, where applicable.
a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial of a
claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the
VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the
provider of services and the claim number. The Covered Person may review, during normal working hours, any documents
held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation
concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the
decision, shall be provided and communicated to the Covered Person as follows:
Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an
appeal from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the
claim, the Covered Person has the right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable
state and federal laws and regulations and shall include the specific reasons for the determination.
c) Other Remedies: When Covered Person has completed the appeals stated herein, additional
voluntary alternative dispute resolution options may be available, including mediation or arbitration. Group should advise
Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally,
under the provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], Covered Person has the right to bring a civil
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action when all available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees with the outcome.
5.07. Time of Action: No action in law or in equity shall be brought to recover on the Policy prior to the
expiration of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be
brought after the expiration of any applicable statute of limitations from the time such claim and invoices are required to be
given, in accordance with the terms of this Policy.
5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly facilitates a fraud, or
submits an application, or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is
grounds for immediate termination of the Policy for the Group or individual that committed the fraud. In the absence of fraud,
all statements made by Group or Enrollees shall be deemed representations and not warranties and no statement made for
the purpose of effecting insurance shall avoid such insurance or reduce benefits unless contained in a written instrument
signed by Group or Enrollee, a copy of which has been furnished t
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VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all
requirements set forth below.
a) Enrollees: To be eligible, a person must:
1. currently be an employee or member of Group, and
2. meet the coverage criteria mutually agreed upon by Group and VSP.
b.) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent
coverage are specified on the attached Schedule of Benefits and Additional Benefit Riders (if applicable).
If a dependent child prior to attainment of the prescribed age for termination of eligibility becomes, and continues to be,
incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's coverage shall
not terminate so long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in
force; PROVIDED that satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty-one (31) days
of the date the Eligible Dependent's coverage would have otherwise terminated and at such other times as VSP may
request proof, but not more frequently than annually.
6.02. Documentation of Eligibility: Persons satisfying the coverage requirements under either of the above
criteria shall be eligible if:
a) for an Enrollee, the individual's name and Member ID Number have been reported by Group to
VSP in the manner provided hereunder; and
b) for changes to an Eligible Dependent's status, the change has been reported by the Group to VSP
in the manner provided herein. As stated in paragraph 4.01 above, VSP may elect to audit Group's records to verify
eligibility of Enrollees and dependents and any errors. Subject to the terms of paragraph 4.03 above, only persons on
whose behalf premiums have been paid for the current period shall be entitled to Plan Benefits hereunder. If a clerical error
is made, it will not affect the coverage a Covered Person is entitled to under this Policy.
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6.03. Retroactive Eligibility Changes: Retroactive eligibility changes are limited to sixty (60) days prior to the
date notice of any such requested change is received by VSP. VSP may refuse retroactive termination of a Covered
Person if Plan Benefits have been obtained by, or authorized for, the Covered Person after the effective date of the
requested termination. As stated in Section 4.01 herein, Group agrees to provide timely eligibility changes to VSP.
6.04. Change of Participation Requirements, Contribution of Fees, and Eligibility Rules: Composition of
the Group, percentage of Enrollees covered unde
material to VSP's obligations under this Policy. During the term of this Policy, Group must provide VSP with written notice of
changes to its composition, percentage of Enrollees covered, contribution and eligibility requirements. Any change which
materially affects VSP's obligations under this Policy must be agreed upon in writing between VSP and Group and may
constitute a material change to the terms and conditions of this Policy for purposes of paragraph 4.02. Nothing in this
section shall limit Group's ability to add Enrollees or Eligible Dependents under the terms of this Policy.
6.05. Change in Family or Employment Status: In the event Group is notified of any change in a Covered
Person's family status [by marriage, the addition (e.g., newborn or adopted child) or deletion of Dependent , etc.] or
employment status, Group shall provide notice of such change to VSP via the next eligibility listing required under
Paragraph 4.01. If notice is given, the change in the Covered Person's status will be effective on the first day of the month
following the change request, or at such later date as may be requested by or on behalf of the Covered Person.
Notwithstanding any other provision in this section, a newborn child will be covered for a period of at least sixty (60) days
after birth, and an adopted child will be covered for a period of at least sixty (60) days after the date the Enrollee or the
sixty (60) day period, VSP shall not deny coverage for said newborn or adopted child. Coverage for an adopted newborn will
begin from the moment of birth if an agreeme
day period, the Group must be properly notified of th
paid to VSP.
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VII.
CONTINUATION OF COVERAGE
7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available to
said persons upon the occurrence of a COBRA-qualifying event. If, and only to the extent, COBRA applies to the parties to
this Policy, VSP shall make the required COBRA continuation coverage available for purchase in accordance with COBRA.
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VIII.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution: Any dispute or question arising between VSP and Group involving the application,
interpretation, or performance under this Policy shall be settled, if possible, by amicable and informal negotiations, allowing
such opportunity as may be appropriate under the circumstances for fact-finding and mediation. If any issue cannot be
resolved in this fashion, it shall be submitted to arbitration where permitted by state law.
8.02. Procedure: Arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration
Association subject to the provisions of Section 10.06 of this Policy. Such Rules, the enforcement thereof, and enforcement
8.03. Choice of Law: If any matter arises in connection with this Policy which becomes the subject of
arbitration or legal process, the law of the State of delivery of the Policy shall be the applicable law.
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IX.
NOTICES
9.01. Notice: Any notices required under this Policy to either Group or VSP shall be in written format. Notices
sent to the Group will be sent to the address or email address shown on the Group's Application unless otherwise directed
by Group. Notices to VSP shall be sent to the address shown on the front page of this Policy. Notwithstanding the above,
any notices may be hand-delivered by either party to an appropriate representative of the other party. The party effecting
hand-delivery bears the burden to prove delivery was made, if questioned.
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X.
MISCELLANEOUS
10.01. Entire Policy: This Policy, the Group Application, the Evidence of Coverage, and all Exhibits, Riders and
attachments hereto, constitute the entire agreement of the parties and supersedes any prior understandings and
agreements between them, either written or oral. Any change or amendment to the Policy must be approved by an officer of
VSP and attached hereto to be valid. No agent has the authority to change this Policy or waive any of its provisions.
Communication materials prepared by Group for distribution to Enrollees do not constitute a part of this Policy.
10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors,
officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of
action and expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its
officers, agents or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to
indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors
and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs
and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers, agents or employees to
perform any of the duties or responsibilities specified herein.
10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with
VSP Network Doctors. VSP Network Doctors are independent contractors and are responsible for exercising independent
judgement. VSP does not itself directly furnish vision care services or supply materials. Under no circumstances shall VSP
or Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or
organization performing services or supplying materials in connection with this Policy.
10.04. Assignment: Neither this Policy nor any of the rights or obligations of either of the parties hereto may be
assigned or transferred without the prior written consent of both parties hereto except as expressly authorized herein.
10.05. Severability: Should any provision of this Policy be declared invalid, the remaining provisions shall
remain in full force and effect.
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10.06. Governing Law: This Policy shall be governed by and construed in accordance with applicable federal
and state law. Any provision that is in conflict with, or not in conformance with, applicable federal or state statutes or
regulations is hereby amended to conform with the requirements of such statutes or regulation, now or hereafter existing.
10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or
plural, as the identity(ies) of the person(s) may require.
10.08. Equal Opportunity: VSP is an Equal Opportunity and Affirmative Action employer.
10.09. Communication Materials: Communication materials created by Group which relate to this vision care
VSP. Such communication
meet any
applicable legal or regulatory requirements, including but not limited to, ERISA requirements. In the event of any dispute
between the communication materials and this Policy, the provisions of this Policy shall prevail.
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EXHIBIT A
SCHEDULE OF BENEFITS
VSP Choice Plan
GENERAL
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY("VSP") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non-VSP
Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider
whether VSP Network Doctors or Non-VSP Providers. This Schedule forms a part of the Policy or Evidence of Coverage to which it is attached.
When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable
subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Plan Benefits are available and
received from Non-VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non-VSP Provider Benefit
column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill
to VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non-VSP Providers.
BENEFIT PERIOD
A twelve-month period beginning on January 1st and ending on December 31st.
ELIGIBILITY
The following are Covered Persons under this Policy:
Enrollee.
The legal spouse of Enrollee.
Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
The domes
Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment because of
mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s) as stated:
COPAYMENT
The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan
Benefits received from VSP Network Doctors and Non-VSP Providers require Copayments. Covered Persons must also follow Benefit Authorization
Procedures.
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses.
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PLAN BENEFITS
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Eye Examination Covered in full*
Up to $ 45.00* Available once each 12 months**
Complete initial vision analysis: includes appropriate examination of visual functions and prescription of corrective eyewear where
indicated.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Lenses Available once each 12 months**
Single Vision Covered in full * Up to $ 30.00*
BifocalCovered in full * Up to $ 50.00*
Trifocal Covered in full * Up to $ 65.00*
Lenticular Covered in full * Up to $ 100.00*
Plan Benefits for lenses are per complete set, not per lens.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
FRAMES Covered up to Plan Allowance* Up to $ 70.00* Available once each 24 months**
Benefits for lenses and frames include reimbursement for the following necessary professional services:
1. Prescribing and ordering proper lenses;
2. Assisting in frame selection;
3. Verifying accuracy of finished lenses;
4. Proper fitting and adjustments of frames;
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow-up work as necessary.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
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SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER FREQUENCY
BENEFIT BENEFIT
CONTACT LENSES
Elective Elective Contact Lens fitting Available once each 12
and evaluation*** services months**
are covered in full once
every 12 months**, after a
maximum $60.00
Copayment.
Materials Professional Fees/Materials
Up to $ 115.00 Up to $ 105.00
**Beginning with the first day of the Benefit Period.
fitting.
Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current
Benefit Period, and future eligibility for lenses and frames will be determined as if spectacle lenses only were
obtained in the current Benefit Period.
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
NECESSARY CONTACT Available once each 12 months**
LENSES
Professional Fees and Covered in full * Up to $ 210.00*
Materials
*Less any applicable Copayment
**Beginning with the first day of the Benefit Period.
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network
Doctor or Non-VSP Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benefit Period.
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SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Low Vision
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing Covered in full Up to $125.00* *
(Includes evaluation, diagnosis and prescription of vision aids where indicated.)
Supplemental Aids 75% of amount 75% of amount *
up to $1000.00* up to $1000.00*
*Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) Benefit Periods.
Low Vision benefits secured from Non-VSP Providers (if covered) are subject to the same time and Copayment provisions described above for
VSP Network Doctors. The Covered Person should pay the Non-
an amount not to exceed what VSP would pay a VSP Network Doctor for the same services and/or materials.
THERE IS NO ASSURANCE TH
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EXCEPTIONS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons
n at (800) 877-7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will
pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.
Optional cosmetic processes.
Anti-reflective coating.
Color coating.
Mirror coating.
Scratch coating.
Blended lenses.
Cosmetic lenses.
Laminated lenses.
Oversize lenses.
Polycarbonate lenses.
Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
Progressive multifocal lenses.
UV (ultraviolet) protected lenses.
Certain limitations on low vision care.
NOT COVERED
There are no benefits for professional services or materials connected with:
Orthoptics or vision training and any associated supplemental testing.
Corneal Refractive Therapy (CRT)
Orthokeratology (a procedure using contact lenses to change the shape of the cornea in order to reduce myopia).
Refitting of contact lenses after the initial (90-day) fitting period.
Plano lenses (lenses with refractive correction of less than ± .50 diopter).
Two pair of glasses in lieu of bifocals.
Replacement of lenses and frames furnished under this Policy that are lost or broken, except at the normal intervals when services are
otherwise available.
Medical or surgical treatment of the eyes.
Corrective vision treatment of an Experimental Nature.
Plano contact lenses to change eye color cosmetically.
Artistically-painted contact lenses.
Contact lens insurance policies or service contracts.
Additional office visits associated with contact lens pathology.
Contact lens modification, polishing, or cleaning.
Costs for services and/or materials exceeding Plan Benefit allowances.
Services or materials of a cosmetic nature.
Services and/or materials not indicated on this Schedule as covered Plan Benefits.
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PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
Affiliate Providers are providers of Covered Services and Materials who are not contracted as VSP Network Doctors but who have agreed to bill VSP
directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included
in this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.
COPAYMENT
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses.
COVERED SERVICES AND MATERIALS
Eye Examination Covered in full * Available once each 12 months**
Comprehensive examination of visual functions and prescription of corrective eyewear.
Spectacle Lenses
Single Vision, Lined Bifocal Covered in Full* Available once each 12 months**
or Lined Trifocal,
Frames Covered up to the Plan allowance* Available once each 24 months**
CONTACT LENSES
Elective Contact Lenses Up to $ 115.00 Available once each 12 months**
(Materials Only)
The Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment.
Necessary Contact Lenses Up to $210.00* Available once each 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
Contact Lenses are provided in place of spectacle lens and frame benefits available herein Future eligibility for lenses and frames will be determined
as if spectacle lenses only were obtained in the current Benefit Period.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
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LOW VISION
Professional services for severe visual problems not correctable with regular lenses, including:
-Includes evaluation, diagnosis and prescription of vision aids where indicated.
Supplemental Aids: 75% of Affiliate
maximum of two supplemental tests within a two-year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a VSP Network Doctor or a Non-VSP Provider.
3. .
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such
entities as a condition of obtaining Plan Benefits.
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Exhibit B
VISION SERVICE PLAN INSURANCE COMPANY (VSP)
SCHEDULE OF PREMIUMS
VSP Choice Plan
and
his/her Eligible Dependents, if any, in the amounts specified below.
$ 4.44 per month for each eligible Enrollee without dependents.
$ 8.88 per month for each eligible Enrollee with an eligible spouse.
$ 9.50 per month for each eligible Enrollee with eligible child(ren).
$ 15.18 per month for each eligible Enrollee with eligible spouse and child(ren).
NOTICE: The premium under this Policy is subject to change upon renewal (after the end of the initial Policy Term or any subsequent Policy Term),
or upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Policy.
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ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
ADDITIONAL BENEFIT RIDER
DIABETIC EYECARE PLUS PROGRAM
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of Benefits with which it is
associated. Plan Benefits under the Diabetic Eyecare Plus Program are available to Covered Persons who have been diagnosed with type 1 or type
2 diabetes and specific ophthalmological conditions. This Rider forms a part of the Policy or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Policy, pursuant to eligibility criteria established by Client:
Enrollee.
The legal spouse of Enrollee.
Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
The domestic partner of the same or
Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
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PROGRAM DESCRIPTION
ers will first
ill be considered
he Coordination of Benefits section of Covered
n, providers will
submit claims directly to VSP.
Examples of symptoms which may result in a Covered Person seeking services under DEP Plus may include, but are not limited to:
blurry vision trouble focusing
transient loss of vision
Examples of conditions which may require management under DEP Plus may include, but are not limited to:
diabetic retinopathy rubeosis
diabetic macular edema
REFERRALS
If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refer the Covered Person to another Member Doctor or to a
physician whose offices provide the necessary services.
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Insured to a physician.
Referrals are intended to insure that Covered Persons receive the appropriate level of care for their presenting condition. Covered Person do not
require a referral from a Member Doctor in order to obtain Plan Benefits.
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PLAN BENEFITS
VSP NETWORK DOCTORS
COVERED SERVICES
Eye Examination: Covered in full after a Copayment of $20.00.
Special Ophthalmological Services: Covered in Full.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Diabetic Eyecare Plus Program provides coverage for limited, vision-related medical services. A current list of these procedures will be made
available to Covered Person upon request. The frequency at which these services may be provided is dependent upon the specific service and the
diagnosis associated with such service.
NOT COVERED
1. Services and/or materials not specifically included in this Rider as Plan Benefits.
2. Frames, lenses, contact lenses or any other ophthalmic materials.
3. Orthoptics or vision training and any associated supplemental testing.
4. Surgery of any type, and any pre- or post-operative services.
5. Treatment for any pathological conditions.
6. An eye exam required as a condition of employment.
7. Insulin or any medications or supplies of any type.
8. Local, state and/or federal taxes, except where VSP is required by law to pay.
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DIABETIC EYECARE PROGRAM DEFINITIONS
DiabetesA disease where the pancreas has a problem either making, or making and using, insulin.
Type 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the insulin it makes to
convert blood glucose to energy.
Diabetic Retinopathy A weakening in the small blood vessels at the back of the eye.
Rubeosis Abnormal blood vessel growth on the iris and the structures in the front of the eye.
Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula.
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ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
PERFORMANCE STANDARDS
VSP guarantees the performance standards outlined herein by offering to pay a financial penalty of 1% of quarterly administrative revenue per unmet
standard, up to a total annual maximum of $100,000 and a minimum annual threshold of $250. VSP's company-wide quarterly performance results
shall be used in determining whether any or all of the performance standards have been met. Any penalties owed shall be accrued quarterly and
paid on an annual basis, as long as the cumulative total for the four quarters exceeds $250. Cumulative annual penalties less than $250 will not be
carried over into the following calendar year for purposes of determining financial penalties. Payment of penalties shall be conditioned on VSP's
receipt of all premiums due to VSP within established due dates.
f God, act of any
government, war or other hostility, the elements, fire, explosion, power failure, equipment failure, industrial or labor dispute. In the event of any such
interruption or delay, any period of performance shall be extended for a period of time equal to the interruption or delay.
CLAIMS PROCESSING
Claims financial accuracy
Performance Standard = 99% processed without financial error
Performance Penalty = 1%
Claims financial accuracy is calculated much like that of claims processing accuracy. The same random sampling of claims audited for processing
accuracy is also audited for financial accuracy. Any error found that results in a financial impact is recorded as a financial error. At the end of the
month, financial errors are totaled and taken as a percentage of the total dollar paid for all claims audited during the given month.
Claims processing accuracy
Performance Standard = 99% processed without error
Performance Penalty = 1%
passes all errors
found in the audit nd
taken as a percentage of the total number of claims audited for the month.
Claims timeliness
Performance Standard:
VSP preferred provider claims = 95% processed within 5 business days
Performance Penalty = 1%
All other provider claims = 95% processed within 5 business days
Performance Penalty = 1%
All other provider claims = 99% processed within 15 business days
Performance Penalty = 1%
Claims timeliness, or turnaround time, is measured on a monthly basis. Each claim audited in the daily audit is audited for timeliness. Timeliness is
measured by calculating the number of business days elapsing between the received date and the pricing date. When additional information is
needed to process a claim, the timeliness date is calculated from the date the information needed to process the claim was received to the pricing
date.
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CALL CENTER MANAGEMENT
Abandoned call rate
Performance Standard = Less than or equal to 3%
Performance Penalty = 1%
The Call Center telephone abandon rate is calculated monthly by taking the total number of abandoned calls before and after sixty (60) seconds,
divided by the total number of calls accepted by the Call Center, which includes calls answered via the Interactive Voice Response and Automated
Call Distribution systems.
Average speed of answer
Performance Standard = Less than or equal to 25 Seconds
Performance Penalty = 1%
The average speed of answer (the amount of time a caller is waiting while on hold) is calculated by dividing the total time all calls are on hold (in
seconds) by the total number of calls received.
Average call blockage rate
Performance Standard = Less than or equal to 2%
Performance Penalty = 1%
is considered
unsuccessful. VSP
blockage standard is 2% or less of total calls attempted to VSP. The formula for this standard is: number of blocked calls divided by (blocked calls
plus accepted calls) as reported by the long distance carrier.
Call resolution (same day response)
Performance Standard = 98%
Performance Penalty = 1%
Measurement based on internal VSP system-driven statistics. The percentage of telephone inquiries handled within the same day is obtained by
taking the number of research inquiries entered into our system and dividing by the number of calls answered in the Call Center, and subtracting the
result from 1.00.
Complaint acknowledgement within 5 business days
Performance Standard = 96%
Performance Penalty = 1%
ness day must be acknowledged in writing within 5 by business days. "Written
complaints" not resolved within 5 business days will be acknowledged in writing on the 5th business day from receipt. Complaint acknowledgement
compliancy is calculated monthly. The method for calculating the percentage is: total number of complaints meeting the 5 business day goal divided
by total number of complaints.
Complaint resolution within 30 calendar days
Performance Standard = 99%
Performance Penalty = 1%
When a complaint is received, in writing or via phone, the person receiving it documents it in our online Research Inquiry system. The Complaint and
Grievance unit monitors this workflow to assure all complaints have been resolved by the 30 calendar day.
th
Average response to e-mail inquiries within 2 business days
Performance Standard = 100%
Performance Penalty = 1%
The average time required to send the first manual reply to an email, in the specified time period.
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SATISFACTION
Patient satisfaction (satisfied with level of coverage)
Performance Standard = 96% overall satisfaction with VSP
Performance Penalty = 1%
Performance Standard = 96% overall experience with VSP preferred provider
Performance Penalty = 1%
VSP conducts patient satisfaction surveys on a quarterly basis. A random sample of claims from the prior three months is chosen that is statistically
representative of all claims.
While VSP makes recommendations to all prospective Groups on which plan we feel best suits the group's employees, the ultimate decision for
selection of a plan rests with the Group. As such, our performance standard is based on patients who are satisfied with the level of coverage
provided by their plan
VSP preferred provider retention rate (based on voluntary turnover)
Performance Standard = 98%
Performance Penalty = 1%
VSP preferred provider satisfaction is based on changes in the VSP preferred provider network. On a quarterly basis, the voluntary retention rate of
providers (those choosing to stay on the VSP panel) is measured as a percentage of the total number of providers in the network. The annual
preferred provider retention rate is equal to the total number of providers on the panel on December 31 divided by the total number of providers on
the panel January 1 of that same year.
ACCOUNT ADMINISTRATION
Electronic eligibility online within 24 hours
Performance Standard = 98%
Performance Penalty = 1%
Percentage reported based on a measurement against all maintenance files* loaded within that quarter. VSP records both the received and loaded
dates for all membership files. The data is compiled into a monthly report, which is used to calculate the quarterly statistical average.
*All files measured for this standard must meet the following criteria:
Identifiable Media: Eligibility file must be labeled properly.
Proper Format: No change in format from the previously loaded eligibility file.
Clean File:
1)Physical Media must be undamaged.
2)Electronic Media must have clean and complete data transmission. We must be able to successfully unzip/decrypt the incoming
data.
3)All media must contain proper/complete records for members and dependents.
Exclusions to this performance standard are as follows:
1)Membership files for open enrollment loaded prior to effective date.
2)Group/division restructures for existing groups (1st eligibility load based on the restructure will be excluded from the
performance standard measurement).
3)Incorrect/Incomplete individual records for members and dependents.
4)If instructed to wait for group approval to load the file.
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Online reports available by the 25 of the month
th
Performance Standard = 100%
Performance Penalty = 1%
All eligible online reports will be available on VSP's Resource Center by the 25th of each month.
Web portal availability
Performance Standard = 99%
Performance Penalty = 1%
Based on a 7 x 24 schedule.
New group implementation
Performance Standard = Satisfaction guaranteed
ts VSP benefit. In support of
this, we are placing a one-time penalty of $100,000 at risk. We will collaborate with MONROE COUNTY BOARD OF COUNTY COMMISSIONERS to
create a customized Implementation Action Plan that includes detailed roles, responsibilities and timeframes to ensure a successful implementation.
Our comprehensive Implementation Action Plan includes the following sections:
Communications
System Accuracy
Plan Accuracy
Membership Management
Preferred Provider Access
Each of the above sections is assigned a maximum penalty amount of $100,000 to be paid in the event VSP was not able to meet MONROE
does not fulfill its obligations as documented in the Implementation Action Plan, no penalty will apply to VSP.
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Group Vision Care Policy
Vision Care for Life
GROUP NAME: MONROE COUNTY BOARD OF COUNTY
COMMISSIONERS
GROUP NUMBER: 30029497
EFFECTIVE DATE: JANUARY 1, 2014
EVIDENCE OF COVERAGE
Provided by:
VISION SERVICE PLAN INSURANCE COMPANY
3333 Quality Drive, Rancho Cordova, CA 95670
(916) 851-5000 (800) 877-7195
EOC FL 1004. 10/31/13 Kav
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To be filled in by employer in the event this document is used to develop a Summary Plan Description:
NAME OF EMPLOYER:
NAME OF PLAN:
PRINCIPAL ADDRESS:
EMPLOYER I.D.#:
GROUP #:
PLAN ADMINISTRATOR:
ADDRESS:
PHONE NUMBER:
REGISTERED AGENT FOR SERVICE OF LEGAL PROCESS, IF DIFFERENT FROM PLAN ADMINISTRATOR:
ADDRESS:
Benefits are furnished under a vision care Policy purchased by the Group and provided by VISION SERVICE PLAN INSURANCE COMPANY (VSP)
under which VSP is financially responsible for the payment of claims.
This Evidence of Coverage is a summary of the Policy provisions and is presented as a matter of general information only. It is not a substitute for
the provisions of the Policy itself. In the event of any dispute between this Evidence of Coverage and the Policy, the provisions of the Policy will
prevail. A copy of the Policy will be furnished on request.
DEFINITIONS:
ADDITIONAL BENEFITS The document, attached as Exhibit C to the Group Policy maintained by the Group Administrator and to this
RIDER Evidence of Coverage, which lists selected vision care services and vision care materials that a Covered
Person is entitled to receive by virtue of the Plan. (Available only if purchased by Group.)
BENEFIT AUTHORIZATION Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying
those Plan Benefits to which a Covered Person is entitled.
COORDINATION OF
BENEFITS payment or reimbursement.
COPAYMENTS Those amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully
covered, and which are payable at the time services are rendered or materials provided.
COVERED PERSON s eligibility criteria and on whose behalf premiums have
been paid to VSP, and who is covered under the Policy.
ELIGIBLE DEPENDENT Any dependent of an Enrollee of Group who meets the eligibility criteria established by Group.
EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate
medical care, or an unforeseen occurrence requiring immediate, non-medical action.
ENROLLEE An employee or member of the Group who meets the eligibility criteria specified under Section VI.
ELIGIBILITY FOR COVERAGE of the Policy.
EXPERIMENTAL NATURE Procedure or lens that is not used universally nor accepted by the vision care profession, as determined by
VSP.
GROUP An employer or other entity that contracts with VSP for coverage under this Policy in order to provide vision
care coverage to its Enrollees and their Eligible Dependents.
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VSP NETWORK DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision
care materials who has contracted with VSP to provide vision care services and/or vision care materials on
behalf of Covered Persons of VSP.
NON-VSP PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not
contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP.
PLAN or PLAN BENEFITS The vision care services and vision care materials that a Covered Person is entitled to receive by virtue of
coverage under the Policy, as defined on the attached Schedule of Benefits and Additional Benefit Rider
(when purchased by Group.)
POLICY The contract between VSP and Group upon which this Plan is based.
PREMIUMS The Payments made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits, as stated
in the Schedule of Premiums attached as Exhibit B to the Group Policy document maintained by the Group
Administrator.
RENEWAL DATE The date on which the Policy shall renew or terminate if proper notice is given.
SCHEDULE OF BENEFITS The document attached as Exhibit A to the Group Policy maintained by the Group Administrator, that lists the
vision care services and vision care materials that a Covered Person is entitled to receive by virtue of the Plan.
SCHEDULE OF PREMIUMS The document attached as Exhibit B to the Group Policy maintained by the Group Administrator, which states
the payments to be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits.
ELIGIBILITY FOR COVERAGE
Enrollees: To be covered, a person must currently be an employee or member of the Group and meet the established coverage criteria mutually
agreed upon by Group and VSP.
Eligible Dependents: If dependent coverage is provided, the persons eligible are indicated on the attached Schedule of Benefits and Additional
Benefit Rider (if purchased by Group.)
PREMIUMS
Group is responsible for payments of the periodic charges for coverage. Group will notify Covered Person of Covered Person's share of the charges,
if any. The entire cost of the program is paid to VSP by Group.
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PROCEDURE FOR USING THE PLAN
1. When Covered Person wants to receive Plan Benefits, contact VSP or a VSP Network Doctor. A list of names, addresses and phone numbers
of VSP Networ
area in which Covered Person desires to seek services, call or write the VSP office nearest Covered Person to obtain one that does.
2. If Covered Person is eligible for Plan Benefits, VSP will provide Benefit Authorization directly to the VSP Network Doctor. If Covered Person
contacts the VSP Network Doctor directly, Covered Person must identify him or herself as a VSP member so the doctor can obtain Benefit
Authorization from VSP.
3. When such Benefit Authorization is provided by VSP and services are performed prior to the expiration date of the Benefit Authorization, this will
constitute a claim again
Person receive services from a VSP Network Doctor without such Benefit Authorization or obtain services from a Non-VSP Provider, Covered
Person is responsible for payment in full to the provider.
4. Covered Person pays the Copayment (if any), amounts that exceed the Plan Allowances, and any amounts for non-covered services or
materials to the VSP Network Doctor for services under this Policy . VSP will pay the VSP Network Doctor directly according to their agreement
with the doctor.
Notice of Claim and Proof of Loss: If Covered Person is eligible for and obtains Plan Benefits from a Non-VSP Provider, Covered Person
s full fee. Covered Person will be reimbursed by VSP in accordance with the Non-VSP Provider reimbursement
schedule shown on the attached Schedule of Benefits and Additional Benefit Rider (if purchased by Group.), less any applicable Copayments.
Covered Person should submit a claim to VSP as soon as possible after services are rendered, but VSP will accept claims up to one hundred
eighty days from the date of services, unless Covered Person is legally incapacitated. No claim form is required but Covered Person should
submit at least the following information: the original bill, invoice or other document from the provider itemizing the services and/or materials
nrollee (Member) and patient; and the date
the services were rendered or the materials provided. Covered Persons may obtain more information on submitting Policy claims
website at www.vsp.com.
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-VSP PROVIDERS ARE USED.
Covered Persons should be aware that when they elect to utilize the services of a Non-VSP Provider for a covered service in non-emergency
situations, benefit payments for services from such Non-VSP Provider are not based upon the amount billed. The basis of the benefit payment
-VSP Provider fee schedule. COVERED PERSONS CAN EXPECT TO BE LIABLE FOR MORE
THAN THE COPAYMENT AMOUNT DEFINED IN THE ATTACHED SCHEDULE OF BENEFITS OR ADDITIONAL BENEFIT RIDER (when
purchased by Group.) AFTER THE PLAN HAS PAID ITS REQUIRED PORTION.
When payment is made to the Non-VSP Provider, the provider may bill Covered Person for any amount up to the billed charge after the Plan
has paid its portion of the bill. VSP Network Doctors have agreed to accept discounted payments for services with no additional billing to the
Covered Person other than Copayments, co-insurance and non-covered services or materials. Covered Persons may obtain further
information about the participating status of providers and information on out-of-
Customer Service Department at 1-800-877-7195.
5. In emergency conditions, when immediate vision care of a medical nature such as for bodily trauma or disease is necessary, Covered Person
can obtain covered services by contacting a VSP Network Doctor (or Non-VSP Provider if the attached Schedule of Benefits and, if purchased
by Group, Additional Benefits Rider, indicates Covered Person's Plan includes such coverage). No prior authorization from VSP is required for
Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical conditions, including
emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare Plans. If there is no Additional Benefit
Rider for one of these plans attached to this Evidence of Coverage, Covered Person is not covered by VSP for medical services and should
contact a physician under Covered Person's medical insurance plan for care.
For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer
Service Department for assistance.
Emergency vision care is subject to the same benefit frequencies, plan allowances, Copayments and exclusions stated herein.
Reimbursement to VSP Network Doctors will be made in accordance with their agreement with VSP.
6. In the event of termination of a
to Covered Person at the time of termination and permit the VSP Network Doctor to continue to provide Covered Person with Plan Benefits until
the services are completed or until VSP makes reasonable and appropriate arrangements for the provision of such services by another VSP
Network Doctor.
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BENEFIT AUTHORIZATION PROCESS
VSP authorizes Plan Benefits according to the latest eligibility information furnished to VSP by Covered Person's Group and the level of coverage
(i.e. service frequencies, covered materials, reimbursement amounts, limitations, and exclusions) purchased for Covered Person by Group under this
Plan. When Covered Person requests services under this Plan, Covered Person's prior utilization of Plan Benefits will be reviewed by VSP to
determine if Covered Person is eligible for new services based upon Covered Per
Schedule of Benefits and Additional Benefit Rider (if purchased by Group.) for a summary of the level of coverage provided to Covered Person by
Group.
BENEFITS AND COVERAGES
Through its VSP Network Doctors, VSP provides Plan Benefits to Covered Persons, subject to the limitations, exclusions and Copayment(s)
described herein. When Covred Person wishes to obtain Plan Benefits from a VSP Network Doctor, Covered Person may contact any VSP Network
Doctor, identify Covered Person as a VSP member, and schedule an appointment. If Covered Person is eligible for Plan Benefits, VSP will provide
t.
Specific benefits for which Covered Person is covered are described on the attached Schedule of Benefits and Additional Benefit Rider (when
purchased by Group.)
COPAYMENT
The benefits described herein are available to Covered Person subject to Covered
this Evidence of Coverage, the Schedule of Benefits and Additional Benefit Riders (when purchased by Group.) Amounts that exceed plan
allowances, annual maximum benefits, options reimbursements, or any other stated Plan limitations are not considered Copayments but are also the
responsibility of the Covered Person.
ANY ADDITIONAL CARE, SERVICE AND/OR MATERIALS NOT COVERED BY THIS PLAN MAY BE ARRANGED BETWEEN COVERED
PERSON AND THE DOCTOR.
COORDINATION OF BENEFITS
Covered Persons who are covered under two or more insurance plans that include vision care benefits may be eligible for Coordination of Benefits
("COB"). VSP will combine other insurance plans' claim payments or reimbursements, if any, with benefits available under Covered Person's VSP
plan, which may reduce or eliminate Covered Person's out-of-pocket expense. Covered Persons covered under more than one VSP plan may also
be able to take advantage of COB. In order to process claims involving COB, VSP may need to share personal information regarding Covered
Persons with other parties (such as another insurance company). When this is necessary, VSP will only share such information with those persons
or organizations having a legitimate interest in that information and only where such sharing is not prohibited by law.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
This vision service plan is designed to cover YLVXDOQHHGV rather than FRVPHWLFPDWHULDOV
Some professional services and/or materials are not covered under this Plan. Please refer to the NOT COVERED section of the attached Schedule
of Benefits and Additional Benefit Rider (when purchased by Group.) for details.
VSP may, at its discretion, waive any of the Plan limitations if, in the opinion of our Optometric Consultants, this is necessary for the visual welfare of
the Covered Person.
LIABILITY IN EVENT OF NON-PAYMENT
IN THE EVENT VSP FAILS TO PAY THE PROVIDER, COVERED PERSON SHALL NOT BE HELD LIABLE FOR ANY SUMS OWED BY VSP
OTHER THAN THOSE NOT COVERED BY THE PLAN.
LEGAL ACTIONS
No legal action may be brought to recover on this Policy within sixty (60) days after a claim has been submitted, and no such action may be brought
after the expiration of the applicable statute of limitations from the time the claim is submitted.
TERMINATION OF BENEFITS
After the Policy Term, this Policy will continue on a month-to-month basis or until terminated by either party giving the other party sixty (60) days
notice. Policy Benefits will cease on the date of cancellation of this Policy whether the cancellation is by Group or by VSP due to nonpayment of
Premium.
If Covered Person is receiving service as of the termination date of the Policy, such service shall be continued to completion, but in no event beyond
six (6) months after the termination date of the Policy.
INDIVIDUAL CONTINUATION OF BENEFITS
This program is available to groups of a minimum of ten (10) employees and is, therefore, not available on an individual basis. When a Group
terminates its coverage, individual coverage is not available for Enrollees who may desire to retain same.
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THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA)
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under certain circumstances, health plan benefits be available
to an eligible participant and his or her dependents upon the occurrence of a COBRA-qualifying event. If, and only to the extent, COBRA applies to
-required continuation coverage available in accordance with COBRA.
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EXHIBIT A
SCHEDULE OF BENEFITS
VSP Choice Plan
GENERAL
This Schedule lists the vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY("VSP") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non-VSP
Provider services, as indicated by the reimbursement provisions below, vision care benefits may be received from any licensed eye care provider
whether VSP Network Doctors or Non-VSP Providers. This Schedule forms a part of the Policy or Evidence of Coverage to which it is attached.
When Plan Benefits are received from VSP Network Doctors, benefits appearing in the VSP Network Doctor Benefit column below are applicable
subject to any applicable Copayments and other conditions, limitations and/or exclusions as stated below. When Plan Benefits are available and
received from Non-VSP Providers, the Covered Person is reimbursed for such benefits according to the schedule in the Non-VSP Provider Benefit
column below, less any applicable Copayment. The Covered Person pays the provider the full fee at the time of service and submits an itemized bill
to VSP for reimbursement. Discounts do not apply for vision care benefits obtained from Non-VSP Providers.
BENEFIT PERIOD
A twelve-month period beginning on January 1st and ending on December 31st.
ELIGIBILITY
The following are Covered Persons under this Policy:
Enrollee.
The legal spouse of Enrollee.
Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance
Dependent children are covered until the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
See schedule below for Plan Benefits, payments and/or reimbursement subject to any Copayment(s) as stated:
COPAYMENT
The benefits herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Plan
Benefits received from VSP Network Doctors and Non-VSP Providers require Copayments. Covered Persons must also follow Benefit Authorization
Procedures.
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses.
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PLAN BENEFITS
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Eye Examination Covered in full*
Up to $ 45.00* Available once each 12 months**
Complete initial vision analysis: includes appropriate examination of visual functions and prescription of corrective eyewear where
indicated.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Lenses Available once each 12 months**
Single Vision Covered in full * Up to $ 30.00*
BifocalCovered in full * Up to $ 50.00*
Trifocal Covered in full * Up to $ 65.00*
Lenticular Covered in full * Up to $ 100.00*
Plan Benefits for lenses are per complete set, not per lens.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
FRAMES Covered up to Plan Allowance* Up to $ 70.00* Available once each 24 months**
Benefits for lenses and frames include reimbursement for the following necessary professional services:
1. Prescribing and ordering proper lenses;
2. Assisting in frame selection;
3. Verifying accuracy of finished lenses;
4. Proper fitting and adjustments of frames;
5. Subsequent adjustments to frames to maintain comfort and efficiency;
6. Progress or follow-up work as necessary.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
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SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER FREQUENCY
BENEFIT BENEFIT
CONTACT LENSES
Elective Elective Contact Lens fitting Available once each 12
and evaluation*** services months**
are covered in full once
every 12 months**, after a
maximum $60.00
Copayment.
Materials Professional Fees and
Up to $ 115.00 Materials
Up to $ 105.00
**Beginning with the first day of the Benefit Period.
fitting.
Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current
Benefit Period, and future eligibility for lenses and frames will be determined as if spectacle lenses only were
obtained in the current Benefit Period.
SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
NECESSARY CONTACT Available once each 12 months**
LENSES
Professional Fees and Covered in full * Up to $ 210.00*
Materials
*Less any applicable Copayment
**Beginning with the first day of the Benefit Period.
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's VSP Network
Doctor or Non-VSP Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses.
Necessary Contact Lenses are provided in lieu of all other lens and frame benefits available herein.
Utilization of contact lens benefits exhausts all of the Covered Person's lens and frame benefits for the current Benefit Period, and future
eligibility for lenses and frames will be determined as if spectacle lenses only were obtained in the current Benefit Period.
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SERVICE OR MATERIAL VSP NETWORK DOCTOR NON-VSP PROVIDER BENEFIT FREQUENCY
BENEFIT
Low Vision
Professional services for severe visual problems not correctable with regular lenses, including:
Supplemental Testing Covered in full Up to $125.00* *
(Includes evaluation, diagnosis and prescription of vision aids where indicated.)
Supplemental Aids 75% of amount 75% of amount *
up to $1000.00* up to $1000.00*
*Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) Benefit Periods.
Low Vision benefits secured from Non-VSP Providers (if covered) are subject to the same time and Copayment provisions described above for
VSP Network Doctors. The Covered Person should pay the Non-
an amount not to exceed what VSP would pay a VSP Network Doctor for the same services and/or materials.
THERE IS NO ASSURANCE TH
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EXCEPTIONS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons
Care Division at (800) 877-7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When a Covered Person selects any of the following extras, the Plan will
pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the additional costs for the options.
Optional cosmetic processes.
Anti-reflective coating.
Color coating.
Mirror coating.
Scratch coating.
Blended lenses.
Cosmetic lenses.
Laminated lenses.
Oversize lenses.
Polycarbonate lenses.
Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
Progressive multifocal lenses.
UV (ultraviolet) protected lenses.
Certain limitations on low vision care.
NOT COVERED
There are no benefits for professional services or materials connected with:
Orthoptics or vision training and any associated supplemental testing.
Corneal Refractive Therapy (CRT)
Orthokeratology (a procedure using contact lenses to change the shape of the cornea in order to reduce myopia).
Refitting of contact lenses after the initial (90-day) fitting period.
Plano lenses (lenses with refractive correction of less than ± .50 diopter).
Two pair of glasses in lieu of bifocals.
Replacement of lenses and frames furnished under this Policy that are lost or broken, except at the normal intervals when services are
otherwise available.
Medical or surgical treatment of the eyes.
Corrective vision treatment of an Experimental Nature.
Plano contact lenses to change eye color cosmetically.
Artistically-painted contact lenses.
Contact lens insurance policies or service contracts.
Additional office visits associated with contact lens pathology.
Contact lens modification, polishing, or cleaning.
Costs for services and/or materials exceeding Plan Benefit allowances.
Services or materials of a cosmetic nature.
Services and/or materials not indicated on this Schedule as covered Plan Benefits.
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PLAN BENEFITS
AFFILIATE PROVIDERS
GENERAL
Affiliate Providers are providers of Covered Services and Materials who are not contracted as VSP Network Doctors but who have agreed to bill VSP
directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included
in this Schedule. Covered Persons should discuss requested services with their provider or contact VSP Customer Care for details.
COPAYMENT
There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses,
frames or Necessary Contact Lenses) are provided, there shall be an additional $20.00 Copayment payable at the time the materials are ordered.
The Copayment shall not apply to Elective Contact Lenses.
COVERED SERVICES AND MATERIALS
Eye Examination Covered in full * Available once each 12 months**
Comprehensive examination of visual functions and prescription of corrective eyewear.
Spectacle Lenses
Single Vision, Lined Bifocal Covered in Full* Available once each 12 months**
or Lined Trifocal,
Frames Covered up to the Plan allowance* Available once each 24 months**
CONTACT LENSES
Elective Contact Lenses Up to $ 115.00 Available once each 12 months**
(Materials Only)
The Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment.
Necessary Contact Lenses Up to $210.00* Available once each 12 months**
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
Contact Lenses are provided in place of spectacle lens and frame benefits available herein. Future eligibility for lenses and frames will be
determined as if spectacle lenses only were obtained in the current Benefit Period.
*Less any applicable Copayment.
**Beginning with the first day of the Benefit Period.
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LOW VISION
Professional services for severe visual problems not correctable with regular lenses, including:
-Includes evaluation, diagnosis and prescription of vision aids where indicated.
maximum of two supplemental tests within a two-year period
Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
1. Exclusions and limitations of benefits described above for VSP Network Doctors shall also apply to services rendered by Affiliate Providers.
2. Services from an Affiliate Provider are in lieu of services from a VSP Network Doctor or a Non-VSP Provider.
3. VSP is unable to re
4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such
entities as a condition of obtaining Plan Benefits.
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ADDENDUM
VISION SERVICE PLAN INSURANCE COMPANY
ADDITIONAL BENEFIT RIDER
DIABETIC EYECARE PLUS PROGRAM
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of Benefits with which it is
associated. Plan Benefits under the Diabetic Eyecare Plus Program are available to Covered Persons who have been diagnosed with type 1 or type
2 diabetes and specific ophthalmological conditions. This Rider forms a part of the Policy or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Policy, pursuant to eligibility criteria established by Client:
Enrollee.
The legal spouse of Enrollee.
Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for adoption with the
Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
eligibility rules.
Any children of the domestic partner provided they depend upon the Enrollee for support and maintenance.
Dependent children are covered up to the end of the year in which they turn age 26.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of self-sustaining employment
because of mental or physical disability, and chiefly dependent upon Enrollee for support and maintenance.
4EGOIX4K
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PROGRAM DESCRIPTION
ers will first
s group medical insurance plan, and then to VSP. Any amounts not paid by the medical plan will be considered
s section of Covered
n, providers will
submit claims directly to VSP.
Examples of symptoms which may result in an Covered Person seeking services under DEP Plus may include, but are not limited to:
blurry vision trouble focusing
transient loss of vision
Examples of conditions which may require management under DEP Plus may include, but are not limited to:
diabetic retinopathy rubeosis
diabetic macular edema
REFERRALS
If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refer the Covered Person to another Member Doctor or to a
physician whose offices provide the necessary services.
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Insured to a physician.
Referrals are intended to insure that Covered Persons receive the appropriate level of care for their presenting condition. Covered Person do not
require a referral from a Member Doctor in order to obtain Plan Benefits.
PLAN BENEFITS
VSP NETWORK DOCTORS
COVERED SERVICES
Eye Examination: Covered in full after a Copayment of $20.00.
Special Ophthalmological Services: Covered in Full.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Diabetic Eyecare Plus Program provides coverage for limited, vision-related medical services. A current list of these procedures will be made
available to Covered Person upon request. The frequency at which these services may be provided is dependent upon the specific service and the
diagnosis associated with such service.
NOT COVERED
1. Services and/or materials not specifically included in this Rider as Plan Benefits.
2. Frames, lenses, contact lenses or any other ophthalmic materials.
3. Orthoptics or vision training and any associated supplemental testing.
4. Surgery of any type, and any pre- or post-operative services.
5. Treatment for any pathological conditions.
6. An eye exam required as a condition of employment.
7. Insulin or any medications or supplies of any type.
8. Local, state and/or federal taxes, except where the Company is required by law to pay.
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DIABETIC EYECARE PROGRAM DEFINITIONS
DiabetesA disease where the pancreas has a problem either making, or making and using, insulin.
Type 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the insulin it makes to
convert blood glucose to energy.
Diabetic Retinopathy A weakening in the small blood vessels at the back of the eye.
Rubeosis Abnormal blood vessel growth on the iris and the structures in the front of the eye.
Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula.
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Summary of Benefits and Coverage
VSP Choice Plan
Prepared for: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Group ID: 30029497
Effective Date: JANUARY 1, 2014
The Affordable Care Act requires that health insurance companies and group health plans provide consumers with a simple
and consistent benefit and coverage information document, beginning September 23, 2012. This document is a Summary of
Benefits and Coverage (SBC).
The grid below is being provided for your convenience and mirrors the sample SBC that the U.S. Department of Labor has
published. All the information provided is relative to your plan and described in detail in the preceding Evidence of
Coverage.
Common Services You Your cost if you use an Limitations and
Medical May Need In-Network Out-of-Network Exceptions
Event Provider Provider
If you or your Eye Exam $10.00 Copay Reimbursed up to Exam covered in
dependents (if $45.00 full every 12
applicable) months**
need eyecare
Frames, Lenses or Glasses: $20.00 Frames reimbursed up Frames covered
Contacts Copay (lenses to $ 70.00 every 24 months**
and/or frames only); SV Lenses reimbursed Lenses covered
Up to $60.00 copay up to $ 30.00 every 12 months**
for Contact Lens Bi-Focal Lenses
Exam reimbursed up to
$ 50.00
Tri-Focal Lenses
reimbursed up to
$ 65.00
Lenticular Lenses
reimbursed up to
$100.00
ECL reimbursed up to
$105.00
Fees
Beginning with the first day of the Benefit Period.
**
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal
or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 800-877-7195.
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3304248MTRUE
3304358FTRUE
3303757FTRUE
3305038MFALSE
3304247MFALSE
3304158FFALSE
3303751FFALSE
3303445MFALSE
3304050MFALSE
3304036FFALSE
3305034MFALSE
3303734FTRUE
3304064MTRUE
3304056FFALSE
3307041MFALSE
3304365MTRUE
3303749FFALSE
3304143FFALSE
3304060FFALSE
3305048FFALSE
3305057FFALSE
3304031MFALSE
3304255MTRUE
3303540MTRUE
3304032MTRUE
4EGOIX4K
'K
3305058FTRUE
3304353FTRUE
3304029MTRUE
3304163MFALSE
3303642MFALSE
3304228MTRUE
3304062FFALSE
3304066FTRUE
3303761MTRUE
3302848FTRUE
3303732FTRUE
3304036MTRUE
3300146MFALSE
3304050FFALSE
3304042FTRUE
3304045MTRUE
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3305059MFALSE
3303748MFALSE
3301544MTRUE
3304048MFALSE
3332454FFALSE
3303757MTRUE
3304328MFALSE
3304078MTRUE
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3304251FFALSE
3305027MFALSE
3304155FTRUE
3305045MFALSE
3305053MTRUE
3304524FTRUE
3304046FTRUE
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3304054FFALSE
3304339MFALSE
3305027MFALSE
3305052FTRUE
3304051MFALSE
3305072FTRUE
3304059MTRUE
3304060FTRUE
3302450FTRUE
3304048FTRUE
3304248MFALSE
3304055MFALSE
3303151MTRUE
4EGOIX4K
'K
3304061FTRUE
3304057FTRUE
3303759MFALSE
3313460MFALSE
3305060MTRUE
3304057MFALSE
3304060MFALSE
3307059MFALSE
3307047FFALSE
3304052FTRUE
3304050FTRUE
3304048MTRUE
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3304052MFALSE
3304055FTRUE
3303254FTRUE
3304055FFALSE
3304072FTRUE
3315540MTRUE
3304242FFALSE
3301049MTRUE
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3304071MTRUE
3304051MFALSE
3304252FFALSE
3303754MFALSE
3305041MFALSE
3304045MFALSE
3305051MFALSE
3318557MFALSE
3304048MFALSE
3304065FTRUE
3303764MTRUE
3303765MFALSE
3317860MFALSE
3317358MTRUE
3304255MFALSE
3301260FTRUE
3315858FTRUE
3304557FTRUE
3304055MFALSE
3304046FTRUE
3304045FFALSE
3304047MTRUE
3304057MTRUE
3304074FTRUE
3304255MFALSE
4EGOIX4K
'K
3304352FFALSE
3304051MFALSE
3303754MFALSE
3302556FTRUE
3303154FTRUE
3304047FFALSE
3316653FFALSE
3316651FTRUE
3304350FFALSE
3305056FTRUE
3304149FTRUE
3304045FTRUE
3307051MFALSE
3304052MTRUE
3304066FFALSE
3303765FFALSE
3307046FFALSE
3304036FFALSE
3304052MFALSE
3305058MTRUE
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3304351MFALSE
3318564MTRUE
3304061FFALSE
3304152FTRUE
3304056FFALSE
3304060FFALSE
3304059FTRUE
3303655FTRUE
3304358MTRUE
3305059FFALSE
3304055MTRUE
3304256FFALSE
3304550MFALSE
3307058MTRUE
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3304046FFALSE
3304059MTRUE
3304058FTRUE
3304056MFALSE
3304052FTRUE
3304060MFALSE
3304349FFALSE
3307056MFALSE
3304254FFALSE
3304051FTRUE
3304256MFALSE
4EGOIX4K
'K
3331352FTRUE
3304059FTRUE
3304049FTRUE
3304051FFALSE
3304254MFALSE
3304156FTRUE
3314956FFALSE
3304254FTRUE
3304240MFALSE
3304052FFALSE
3303047MTRUE
3304045FFALSE
3304061MTRUE
3304260MFALSE
3304038FFALSE
3307060FFALSE
3318353FTRUE
3304044MFALSE
3304045FFALSE
3304050FFALSE
3317867FTRUE
3307036MFALSE
3305050MFALSE
3304052FFALSE
3304064FTRUE
3304067MFALSE
3304066MTRUE
3307047FFALSE
3304049MFALSE
3304064MTRUE
3304062MFALSE
3304561MFALSE
3300963FTRUE
3304061FTRUE
3304061MFALSE
3305061MFALSE
3304060FFALSE
3304060MFALSE
3304059FTRUE
3302659FTRUE
3307058MFALSE
3304053MTRUE
3301857MFALSE
3303749FTRUE
3304041FTRUE
3303654MFALSE
3304055FTRUE
4EGOIX4K
'K
3305054FFALSE
3305055MFALSE
3304055MFALSE
3304053FTRUE
3304057FFALSE
3304547FFALSE
3304054FFALSE
3304041FTRUE
3304069MFALSE
3304269MFALSE
3304356FTRUE
3303765FFALSE
3304051FTRUE
3304053FFALSE
3313365MTRUE
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3304351MFALSE
3303765MFALSE
3304367FTRUE
3305051FFALSE
3303769FTRUE
3307061FTRUE
3307056MFALSE
3304357MTRUE
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3304157MTRUE
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3304054MFALSE
3304148FTRUE
3304048FFALSE
3304054MFALSE
3304048FFALSE
3304046FFALSE
3304058FFALSE
3318754MTRUE
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3304053MFALSE
3304553FFALSE
3304247FFALSE
3303753MFALSE
3304062MFALSE
3305051FFALSE
3307050FTRUE
3304038FFALSE
3304252MFALSE
4EGOIX4K
'K
3304041MFALSE
3304557FTRUE
3303346MTRUE
3303766MTRUE
3307053FTRUE
3304050MFALSE
3305052FTRUE
3305064FTRUE
3304049FFALSE
3304049MFALSE
3304061MFALSE
3305062FFALSE
3304060FFALSE
3305057FFALSE
3304353FFALSE
3317047MTRUE
3304052FFALSE
3304056MTRUE
3304057FTRUE
3304157FTRUE
3304054MTRUE
3304057MFALSE
3304055FFALSE
3304056FFALSE
3307048MTRUE
3305056MFALSE
3303754MFALSE
3304041FTRUE
3304045FTRUE
3304052FTRUE
3303754MTRUE
3304053MFALSE
3304040FFALSE
3304052FTRUE
3307052FTRUE
3304049MFALSE
3304039FFALSE
3303239MFALSE
3304067MFALSE
3304251FFALSE
3317649FTRUE
3304253MFALSE
3304249FFALSE
3304152FFALSE
3304144FFALSE
3304048MFALSE
3303741MTRUE
4EGOIX4K
'K
3304051MFALSE
3304036FFALSE
3303363MFALSE
3304052FFALSE
3303752MFALSE
3304361MFALSE
3304058FFALSE
3304361MTRUE
3307658MTRUE
3303758FFALSE
3304048MTRUE
3303654FTRUE
3304050MFALSE
3304270MFALSE
3303755MTRUE
3304052FTRUE
3304051FFALSE
3311672MTRUE
3304039MTRUE
3305068MTRUE
3301549FFALSE
3305064FFALSE
3304054MFALSE
3303759FTRUE
3304043FTRUE
3303772MTRUE
3305060MFALSE
3304338FTRUE
3304543MTRUE
3304041MTRUE
3305039FTRUE
3304365FTRUE
3304145FFALSE
3304323MTRUE
3307053MFALSE
3304045FFALSE
3304245MFALSE
3304244FFALSE
2681041MTRUE
3304056MFALSE
3307040MTRUE
3304249MTRUE
3304046MFALSE
3304052MTRUE
3307035MTRUE
3305156FTRUE
3305042MFALSE
4EGOIX4K
'K
3305051MFALSE
3307054MFALSE
3304365MFALSE
3303762MFALSE
3304343FFALSE
3304049FTRUE
3304358MFALSE
3304061FTRUE
3304046MTRUE
3304035MFALSE
3304065FTRUE
3303756MFALSE
3304357FFALSE
3305049MFALSE
3304274MFALSE
3305032FTRUE
3304038FFALSE
3303634MFALSE
3304357FFALSE
3304056FFALSE
3304021MTRUE
3304341FFALSE
3305035MFALSE
3303756FFALSE
3304263MFALSE
3304027MTRUE
3304041FFALSE
3307050MTRUE
3305051MFALSE
3312669FFALSE
3304058MTRUE
3304038MFALSE
3303752FTRUE
3304061FTRUE
3307061FFALSE
3305149FTRUE
3303751MFALSE
3307034MTRUE
3304351FFALSE
3304346MFALSE
3303764FTRUE
3305144MTRUE
3303732MTRUE
3303041MFALSE
3303741FFALSE
3304061FTRUE
3303765FTRUE
4EGOIX4K
'K
3304259FFALSE
3305040FFALSE
3303769MFALSE
3304049FTRUE
3304254FTRUE
3305035FFALSE
3304326FTRUE
3304058MTRUE
3304055FFALSE
3307055FTRUE
3304056MTRUE
3305050FTRUE
3305049FTRUE
3307045MFALSE
3304548MTRUE
3304041MTRUE
3303756FFALSE
3304045MFALSE
3303763FTRUE
3304252MFALSE
3304056FFALSE
3303760MTRUE
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3304352FTRUE
3304035MTRUE
3307075FTRUE
3304062FFALSE
3304262MTRUE
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3304055FTRUE
3304040FTRUE
3303742MTRUE
3303628FFALSE
3304355FFALSE
3305040MFALSE
3304058FFALSE
3307051MTRUE
3304057MTRUE
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3307045MTRUE
3304054FFALSE
3304054MFALSE
3304050FTRUE
3304068MTRUE
3307056FTRUE
3304052MFALSE
3314057FFALSE
4EGOIX4K
'K
3306358FFALSE
3304047MFALSE
3303547MFALSE
3304333MFALSE
3303136FFALSE
3304050FTRUE
3304037MTRUE
3304045MFALSE
3305061FTRUE
3304070MTRUE
3305040FTRUE
3304046FTRUE
3304050FFALSE
3304038FTRUE
3304152FFALSE
3304063FTRUE
3304035MTRUE
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3304032FTRUE
3303346MTRUE
3305072MFALSE
3307036MFALSE
3305067MFALSE
3304362FFALSE
3304244MTRUE
3333151MFALSE
3304260MTRUE
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3303650MTRUE
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3305065MTRUE
3304257MFALSE
3303533FTRUE
3307048MTRUE
3303744FFALSE
3304235MFALSE
3304535FTRUE
3304063MFALSE
3305060MFALSE
3304048MTRUE
3304040MTRUE
3304039MFALSE
3304052MTRUE
3304356FFALSE
3303530FFALSE
4EGOIX4K
'K
3304262MTRUE
3304360FFALSE
3304267MTRUE
3307050FFALSE
3319650MFALSE
3304245MFALSE
3305055FFALSE
3304264FTRUE
3498254MFALSE
3303753MFALSE
3305049FFALSE
3303743FFALSE
3303753FFALSE
3305030MTRUE
3304030FTRUE
3304330MFALSE
3305050FTRUE
3304058FFALSE
3305061MTRUE
3305060FTRUE
3304260FFALSE
3303634FFALSE
3317855FTRUE
3304053FTRUE
3216934FFALSE
3304056FTRUE
3305056FFALSE
3317850FFALSE
3304258MTRUE
3307056MFALSE
3304254FFALSE
3304258MFALSE
3303664MFALSE
3304353MTRUE
3304360FFALSE
3303556MFALSE
3305061MTRUE
3303757MTRUE
3304034MFALSE
3304038MTRUE
3303031MFALSE
3304055MFALSE
3307062MFALSE
3303759FFALSE
3305045FFALSE
3304354MFALSE
3304055FFALSE
4EGOIX4K
'K
3304043MTRUE
3304073MTRUE
3303543FFALSE
3304064FFALSE
3303337FFALSE
3304255MFALSE
3315047FFALSE
3304046FTRUE
3304235FFALSE
3305048FFALSE
3319325MFALSE
3304051FTRUE
3305025MTRUE
3304347FTRUE
3304035FFALSE
3304025FFALSE
3304225MTRUE
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3303747FTRUE
3304549MTRUE
3304040FFALSE
3304038FTRUE
3303134FTRUE
3318056FFALSE
3304033FFALSE
3305050FTRUE
3317033MFALSE
3304034FFALSE
3303223MTRUE
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3318645FFALSE
3304047MFALSE
3303728FFALSE
3303746FTRUE
3304031FFALSE
3303744MFALSE
3303045MFALSE
3304529MTRUE
3304033FTRUE
3317731MFALSE
3303734FFALSE
3304021FTRUE
3303735FFALSE
3304246FTRUE
3304229FTRUE
3304033FTRUE
4EGOIX4K
'K
3303529MFALSE
3304028FFALSE
3305141FFALSE
3317331MFALSE
3307026MTRUE
3305531MFALSE
3314232MFALSE
3303329MFALSE
3303774MFALSE
3318928MTRUE
3304032MTRUE
3304153FTRUE
3307127MTRUE
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3317026MFALSE
3317230FFALSE
3304237MFALSE
3303732MFALSE
3304025FFALSE
3319325MTRUE
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3304029FTRUE
3304049FFALSE
3317543MFALSE
3319047MFALSE
3303738FTRUE
3305038FFALSE
3304344FTRUE
3304044FFALSE
3315524MTRUE
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3307128MFALSE
3304033FTRUE
3304049FTRUE
3305035FTRUE
3304047FFALSE
3301532MFALSE
3307040MFALSE
3304331MFALSE
3304032FTRUE
3304047MFALSE
3304022FTRUE
3304056MTRUE
3317531MFALSE
3304031FFALSE
3307043FTRUE
3305043MFALSE
4EGOIX4K
'K
3302836MTRUE
3304030FFALSE
3303732FFALSE
3307041MFALSE
3304041FFALSE
3304052MFALSE
3307038MFALSE
3332434MFALSE
3305542MFALSE
3304034FFALSE
3317464MFALSE
3304061FFALSE
3303450MTRUE
3304024MFALSE
3304327MTRUE
3304027MTRUE
3304065FTRUE
3316627MTRUE
3304045FFALSE
3304345FFALSE
3303026MFALSE
3303632FTRUE
3303726MFALSE
3305045FTRUE
3305045MTRUE
3304248FFALSE
3304041FFALSE
3303335FTRUE
3332450FFALSE
3303745FFALSE
3303727MTRUE
3307035MFALSE
3304034FFALSE
3304047FTRUE
3304035MFALSE
3304038MFALSE
3304024FTRUE
3303724MFALSE
3317524MTRUE
3317747MTRUE
3316933FTRUE
3317748MFALSE
3302744FTRUE
3304049FFALSE
3304033MTRUE
3304044MTRUE
3304032MTRUE
4EGOIX4K
'K
3304047FFALSE
3343031FTRUE
3304043FFALSE
3305048MFALSE
3303749MTRUE
3304034FTRUE
3304030FTRUE
3303061MFALSE
3305026FTRUE
3304044FTRUE
3307044FTRUE
3304035MTRUE
3304037FTRUE
3307036FTRUE
3304143FTRUE
3304238FTRUE
3303733FFALSE
3318729MTRUE
3304346MFALSE
3305643FFALSE
3304028MTRUE
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3305028MFALSE
3304033MTRUE
3304039MFALSE
3304064FTRUE
3313965FTRUE
3304030FTRUE
3304032MTRUE
3315727MTRUE
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3304032FFALSE
3305033FFALSE
3303726MTRUE
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3303035MFALSE
3304025FTRUE
3303745MFALSE
3304025MTRUE
3304147FFALSE
3304025FTRUE
3304025FTRUE
3303746MFALSE
3304350MFALSE
3303642MFALSE
3304047FTRUE
4EGOIX4K
'K
3303724MTRUE
3304034FFALSE
3317547MFALSE
3304055MFALSE
3301235MFALSE
3307043FTRUE
3303732MFALSE
3312623MTRUE
3304041FFALSE
3305038MFALSE
3303737MTRUE
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3303523MFALSE
3304323FTRUE
3304047FFALSE
3304042MTRUE
3304045FFALSE
3314334MTRUE
3304040MTRUE
3303022FTRUE
3304246FTRUE
3302829MTRUE
3304044MFALSE
3304346FFALSE
3317740MFALSE
3303553FFALSE
3314330MTRUE
3304130FTRUE
3305036FFALSE
3304239FTRUE
3305033MTRUE
3304030FTRUE
3304040FFALSE
3301826MFALSE
3305031MTRUE
3317543FFALSE
3304044FTRUE
3304028MTRUE
3304029FTRUE
3304049FFALSE
3317528MTRUE
3301027MFALSE
3304227FTRUE
3307034MFALSE
3304032MTRUE
3304026MTRUE
3303730MFALSE
4EGOIX4K
'K
3303736MFALSE
3303751MFALSE
3304042FFALSE
3304338MTRUE
3303143MFALSE
3302527MFALSE
3304044FTRUE
3314546MTRUE
3304029MFALSE
3304035MTRUE
3304237FFALSE
3317726MFALSE
3307039MFALSE
3304034FFALSE
3316524MFALSE
3304047FFALSE
3304036FFALSE
3304246MFALSE
3304347FTRUE
3304040FFALSE
3303732MFALSE
3307032MFALSE
3304022FFALSE
3304542MTRUE
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3305430FFALSE
3317524FTRUE
3304349MTRUE
3307045MFALSE
3303329MTRUE
3305042MFALSE
3319429MTRUE
3303642FFALSE
3303734FTRUE
3307075MTRUE
3304037MFALSE
3304036MFALSE
3301336MFALSE
3304031MFALSE
3302927MTRUE
3304027FTRUE
3303428MTRUE
3304027FFALSE
3304059FTRUE
3304332MFALSE
3303627MFALSE
3304240MFALSE
4EGOIX4K
'K
3305031MFALSE
3332428MFALSE
3317632MFALSE
3307041MFALSE
3315734MTRUE
3304026FTRUE
3304026FFALSE
3304033FTRUE
3304225MFALSE
3307051MFALSE
3303728MTRUE
3303550FTRUE
3304045MTRUE
3315725MTRUE
3307043MTRUE
3304024FFALSE
3304223FTRUE
3302332MTRUE
3304049FFALSE
3304245MFALSE
3303031FFALSE
3304053MTRUE
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3304030FFALSE
3331341FFALSE
3304047MTRUE
3303745FTRUE
3303241MTRUE
3304036FFALSE
3304034MTRUE
3304129MTRUE
3304024MFALSE
3318747MFALSE
3304336MTRUE
3304033MFALSE
3318536MTRUE
3303330MFALSE
3304029FTRUE
3304244MTRUE
3303727MFALSE
3318635MFALSE
3343227MFALSE
3331750MFALSE
3304327FTRUE
3303541MTRUE
3304032FFALSE
3304260FTRUE
4EGOIX4K
'K
3304226MFALSE
3305036FFALSE
3304030MTRUE
3304065MTRUE
3303243MFALSE
3318445FFALSE
3303728MTRUE
3317366MFALSE
3304041FFALSE
3304332MFALSE
3307038FFALSE
3303140MTRUE
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3304043FFALSE
3304034MTRUE
3305047FTRUE
3303323MFALSE
3305023MTRUE
3302335MFALSE
3303533FTRUE
3307044FFALSE
3305021MTRUE
3313032MTRUE
3304039FTRUE
3305037MFALSE
3349328MTRUE
3305029MTRUE
3319331MTRUE
3304031FTRUE
3304026MTRUE
3303341MFALSE
3304027FFALSE
3317643MFALSE
3318937MFALSE
3318628MFALSE
3318634MFALSE
3304027MTRUE
3303531MFALSE
3303427MTRUE
3304037FFALSE
3303026MTRUE
3304026FTRUE
3307025FTRUE
3303330MFALSE
3304032FFALSE
3304026MTRUE
3304036FTRUE
4EGOIX4K
'K
3303745MFALSE
3303348MTRUE
3304024MFALSE
3304328MTRUE
3301544MFALSE
3304024FTRUE
3304027MTRUE
3304028FTRUE
3305052MFALSE
3304025MTRUE
3304025MFALSE
3305048FFALSE
3304030FFALSE
3304024MFALSE
3304067FTRUE
3307053MFALSE
3304054MFALSE
3305033FTRUE
3304350MFALSE
3307050FFALSE
3307041MFALSE
3304030MTRUE
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3304028MTRUE
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3304029FTRUE
3304043MFALSE
3307045FTRUE
3304045FTRUE
3304557MFALSE
3301225MTRUE
3304357MFALSE
3301031MFALSE
3304028MFALSE
3303744MFALSE
3304030FFALSE
3304035MFALSE
3303634FFALSE
3304229MTRUE
3303226MTRUE
3315625MTRUE
3315528MTRUE
3304327MFALSE
3304043FFALSE
3307054MTRUE
3302825FTRUE
3301939FTRUE
4EGOIX4K
'K
3319624MTRUE
3303737MTRUE
3303652FTRUE
3303733MFALSE
3304027FTRUE
3304019MTRUE
3304024FTRUE
3304024MTRUE
3303749FFALSE
3303124MTRUE
3304024FTRUE
3304021FTRUE
3303731MFALSE
3307024MTRUE
3304047FTRUE
3304021MFALSE
3303228MFALSE
3304036FFALSE
3305145MFALSE
3318629MTRUE
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3305034FFALSE
3305069FFALSE
3304254MTRUE
3304041MFALSE
3303663FFALSE
3304061MTRUE
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3304348MFALSE
3304242MFALSE
3304262FFALSE
3304063MFALSE
3305058FFALSE
3303375MFALSE
3304056MFALSE
3212870MTRUE
3304039FFALSE
3304249MTRUE
3304261FFALSE
3303651FFALSE
3315765MFALSE
3304051FFALSE
3304052MFALSE
3307060FFALSE
3305042MFALSE
3303761MFALSE
3304345MFALSE
4EGOIX4K
'K
3303767MFALSE
3304049FFALSE
3303771MFALSE
3303048FTRUE
3305028FFALSE
3304033FFALSE
7046051MFALSE
3318636FTRUE
3304040MFALSE
3304369FTRUE
3304049MFALSE
3304252FFALSE
3304226MFALSE
3304035MFALSE
3304022MFALSE
3304022FFALSE
3304346FFALSE
3307020MFALSE
3304048FFALSE
3304250MFALSE
3302549MFALSE
3377845FFALSE
3318639MFALSE
3302648MFALSE
3304044FFALSE
3304023MTRUE
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3303724FFALSE
3304356MTRUE
3304022MFALSE
1692750FTRUE
3304249FFALSE
3380161FTRUE
3218073MFALSE
3447273FTRUE
0102268FTRUE
3217363MTRUE
3304164FFALSE
3305065MFALSE
3314366FFALSE
3385267MFALSE
3303763MFALSE
3989770MTRUE
3303675MFALSE
3304072FTRUE
3377172MFALSE
3153564FTRUE
4EGOIX4K
'K
3469869MFALSE
3304064MTRUE
3443267MTRUE
3304264FFALSE
3304267FTRUE
3394778MTRUE
3389866FTRUE
3499768MFALSE
3305070MTRUE
3304558MFALSE
3275765FFALSE
3351192FTRUE
3265569MTRUE
3343765FFALSE
3343675MFALSE
3385985MTRUE
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3348472FFALSE
3387568FFALSE
3304057MTRUE
3498669FFALSE
3303150MFALSE
3304073MTRUE
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3304062FFALSE
3266871FTRUE
3307083MFALSE
3305066MFALSE
3301967MTRUE
3303461FTRUE
3332187MTRUE
3305077FFALSE
3385285MFALSE
3293767FTRUE
3304071MTRUE
3307069MFALSE
3265566FTRUE
3303776FTRUE
3302466MTRUE
3303768MFALSE
3390479MFALSE
2296367MTRUE
3307061FTRUE
0701671MFALSE
3304372FFALSE
3303668FFALSE
4EGOIX4K
'K
3304362MTRUE
3305080MFALSE
3305070FTRUE
3307059MTRUE
3304368MFALSE
3304074MFALSE
3305071MTRUE
3305054MFALSE
3273869FFALSE
3315567FFALSE
2740765FFALSE
3303667MFALSE
3214859FFALSE
3304058FTRUE
3304079MTRUE
3275774MTRUE
3307066FTRUE
3304072FTRUE
3234851MFALSE
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4EGOIX4K
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MONROE COUNTY COMMISSIONERS
ATTACHMENT D - CURRENT VISION RATES
Employee Only$4.44
Employee + Spouse$8.88
Employee + Child/Children
$9.50
Employee + Family$15.18
The above rates have been in effect since January 1, 2012
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