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Item C2
N D11:1 III N I amlo I I - "t - . 1. 111 - 1 0 0 -- : Ext. 4448 AGENDA ITEM WORDING: Discussion and approval to advertise a solicitation for proposals for Medical Stop Loss Insurance with staff signing the necessary forms. ETEM BACKGROUND: August 2001 the BOCC approved for the county to be self -insured for Specific & Excess Stop Loss Coverage, therefore canceling the Stop Loss policy effective October 1, 2001. During the October 16, 2013 BOCC meeting the BOCC requested that we revisit the possibility tf purchasing Specific & Excess Stop Loss Coverage. PREVIOUS RELEVANT BOCC ACTION: N/A CO11TRACT/AGREEMENT CHANGES: *NOTE: The Stop Loss R.FP requires that the Proposers accept the extended grace period allowed under the Florida Prompt Payment Statutes. However, in order to implement a new policy of insurance, a check in the amount of the estimated first month's premium is required. This check is sometimes required along with the application, but in any case it will be required before the coverage becomes effective. This is referred to as a "binder check". Advertising Approx TOTAL COST: $800.00 INDIRECT COST: BUDGETED: Yes X No 113 1 :1 i 1111] lii mu-SON01114 Internal Service Fund COST TO COUNTY: $800.00 advertising SOURCE OF FUNDS: Primarily Ad Valorem REVENUE PRODUCING: Yes No AMOUNT PER MONTH Year APPROVED BY: County Arty OMB/Purchasing Risk Management DOCUMENTATION: Included Not Required 401SPOSITION: AGENDA 1-1la—Mt-WHIE REQUEST FOR PROPOSALS FOR MEDICAL PLAN STOP LOSS INSURANCE BOARD OF COVITT COffilynISSIOlIERS Mayor, Sylvia J. Murphy, District 5 Mayor Pro Tem, Danny L. Kolhage, District George Neugent, District 2 Heather Carruthers, District 3 David Rice, District 4 COUNTY ADMINISTRATOR Roman Gastesi CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION Amy Heavilin Employee Benefits :::21M w F: 156- WOT ON 111560 F� I ON [.*Y ffs L VION ISH &I w fel a 1 -1019 X-4 r ,zUr ft I 0 a 91 a A. Mealth Plan Documents B. Summary of Benefits and Coverage (SB CMedical Plan Census D. Claim Data by Month — Medical and Rx E. Large Claims > $50,000 — 2013 — 2014 F. Large Claims > $50,000 — 2011 — 2013 G. Lag Report — Medical H. Stop Loss Questionnaire 1. Stop Loss Pricing Form I I III IIIIIIIIIIIIII:rIIIIIIII 11��111111��Iij 11111111 � I 1 11!111111111 Offili, Ifigilo:11 .'LlIr The County is seeking an insurance vendor to provide the County with a stop loss insurance policy for its self -insured health plan in accordance with the specifications outlined in this Request for Proposals. Deductible $300,000 $400,000 $500,000 Contract 15/12 and Paid Lifetime Max: Unlimited A99. Corridor 125% Annual Lkgg Max- Unlimited Requested Commission None The County may elect to purchase only Specific Stop Loss coverage. Please indicatff- in the official Pricing Attachment, whether there is an impact to your rates if the Aggregate coverage is not elected. H§�■ Date Activity RFP Release Date Deadline for Vendor Questions Addendum Release Date Bid Opening - 3:00 PM. No late bids will be accepted Selection Committee Ranking Meeting Monroe County BOCC Meeting - Bid Award October 1, 2014 Policy Effective Date . . . . . . . . . . . . . . . . . . . . 9 IF I A I oroer to carry 111(inis jiL ion, 5M %T1111tj M 1111pluMu tu Nvy Meb tu pa:T trie CUSL 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.monroecountILl.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 (pitimarily Plantation Key and Key Largo) in addition to Key West, with employees stationed in all locations. 4. Present Information W W 9 -talar-MR11 I I A before May 2012 and charges $50 per month for employees hired beginning May 2012. The current (as of January 1, 2014) employee only medical cost is approximately $456 per month. The County subsidizes approximately 50% to 60% of the dependent costs and subsidizes a significant portion of retiree premiums. Employee contributions for dependents are made through payroll deductions. The estimated enrollment breakout is as follows: Employee Only: 1,167 Spouse Only: 193 Employee + Child or Children: 122 Full Family: 117 Included in the above enrollment there are Retirees as follows: Retiree Only: 299 Spouse Only: 87 Retiree + Child or Children: 3 Full Family: 3 Lit M W4 VJ; 0 ............. e paid and your reason(s) for including them. A Selection Committee will be convened to review the Proposals and recommend which individual or firm should be selected for the project. The successful Proposer will be selected based on the following criteria. Cost of services 30 points Experience and qualifications 20 points Amount and breadth of coverage and 20 points exclusions Compliance with the Bid Specifications 10 points Recommendations from government 10 points clients Acceptance of the Florida Local 5 points Government Prompt Payment Act, Section 218.70, F.S. payment parameters Location of firm (local preference if 5 points applicable: up to 5 additional paints Total points earned are ■ a scale ■ I — 100 points I = lowest 100 = highest County Administrator who will ultimately make a recommendation to the Board of County Commissioners regarding which Proposer should be hired. There will not be an interview process and Proposers will not be permitted to submit revised proposals after the Bid Opening. Please ensure that you have submitted your best and final offer for the Bid Opening. P M Z 7--ra M—TT4 M F. M X: 17, MOM MM 1111111 11 � ��pj � � 111111 !11 [fill RZKOJORIA-i a tol a I I Pr4VVDIIII H 49:4021:111LIVII-I u IR ILI! 110-4-111 Maria Gonzalez, Sr. Benefits Administratur 1100 Simonton Street, Suite 2-268 Key West, Florida 33040 Facsimile (305) 292-4452 All requests for additional information must be received no later than 3:0' PM ...... 20 . Any requests received after that date and time will not be answered' . All questions received prior to the deadline will be answered to the best of the County's ty ability and will be distributed to all interested Proposers in the form of an Addendum to the RFP. All questions must be submitted in writing. Oral reguests will not be answered. ME20TIM, M- I Rif II 11sm-M-1 OLO MINIZA dvjj#14�90 Tab 1. Executive Summary The Proposer shall provide a narrative of the firm's qualities and capabilities that temonstrates how the firm will work with the County to fulfill the requirements of this Service. rim-li The Proposer shall be licensed in the State of Florida to provide the requested insurance. The Proposer shall have an A.M. Best rating of A- or higher and a financial size category of V1 or higher. If the Proposer is not rated by A.M. Best or the A.M. Best rating is below proposer must submit three (3) years of independent audited financial statements. a The Proposer shall provide a minimum of five (5) customer references. At least two (2) of these references must be from other governmental entities within the State of Florida. Two (2) of the references must be from former customers. Each reference at a minimum shall include: o Name and full address of the client; o Name, address, title, and telephone number of the client contact; o Identification of coverage provided; and -D The length of time the policy was in place. The Proposer shall provide copies of all required licenses/certifications and/or authorizations to conduct business in the state of Florida. The Proposer shall provide evidence of active insurance policies in the type and amounts specified under Item 18, Certificate of Insurance and insurance requirements. .2= • Please include Section 2: Scope of Services, under this tab. • If your response indicates that you can comply to the Scope of Services but with deviations, you must fully explain the deviations in this Tab. . Attachment I is the official pricing form and is to be provided under this Tab. No other documents will be utilized for assessing the Cost of this service. Please provide all of the parameters and contingencies for your price quote on this form. UPT r 17--W t IN, ra r, r I M- The Proposer shall include Attachment H — Stop Loss Questionnaire under Tab 5 in the hard copy Proposal. The Proposer shall also include Attachment H — Stop Loss Questionnaire, in the electronic version in the original Excel format. Please note that the Attachment H — Stop Loss Questionnaire is an Excel document that is protected and the number of characters in each response is limited. The questions are designed to allow for brief answers and excessive verbiage will not be an advantage to the Proposer, As shown in the instructions, if your answer must exceed the space allocated in the Excel document, you will have the opportunity to include youv complete response under Tab 6. The successful Proposer will be required to sign a Business Associate Agreement covering HIPAA and HITECH issues. The Proposer shall provide copies of all materials that the County will bg required to sign in order to implement the Stop Loss Insurance Policy, including but not limited to: a sample policy for the State of Florida, application for Stop Loss Insurance, Required Disclosure Forms, Claim Forms, etc. Proposer shall provide any additional project experience not already tescribed in other tabs that will give an indication of the Proposer's overall abilities. If the Proposer cannot fully provide any of the elements in scope of services, Section 2, or any other elements of this Request for Proposals, these must be spelled out in Tab 6 and labeled "Deviations". UMWNNNKI�� In accordance with Section 2-347(h) of the Monroe County Code, the Proposer must *rovide the following infonnation: Forms: • Submission Response Form • Lobbying and Conflict of Interest Ethics Clause • Non -Collusion Affidavit * Request for Waiver of Insurance Requirements * 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. 1. Complete sets of RFP Documents may be obtained in the manner and at the locations stated in the Notice of Request for Proposals. 4.1w-M. 74721SUMM-2 4. ne -.09-MM, a JAI. 1 41, i U1 =1 0167 L.-OMP-Iff-11111 1:11411% 1:101.1 K-0j... 22-'Zkyj 0.0 M. .4 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, 10of43 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. P*BLIC ETATI-FT CRIME: A person or affiliate who has been placed on t 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 I may not transact business with any public entity in excess of the thresholl 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 t* 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. 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. pl-114 0 pis low, itm 1621 im a] sirm V. responsibility of the Proposer. 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. liEN &M Q I 9156K.1-111 11541 Zral-A.11 9 W. 1 WOMRIN01W-2 I I N. I I W#E A I L4141 I I Iffin.111 *a] 4 [:A 011011 ax. 01:1 =11,01 I Ul LeXIIA 1.4 *111:141 ki W Z Responses that contain modifications that are incomplete, unbalanced, conditional, abscure, 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 #ption of the County. .J W-11 Elton KZCITIG VIZI IIMZARW�l IRSIASNU 11 1 1111 111FIRIC1101111MV-44-1141 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. "We M911-11 HIM.-] Egli IZI&RDIELTALNUMNIAM6111i xym a [film lav�m a 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 addition 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 havi an agent for service of process in the State of Florida. Companies shall have an A.M. Best rating of V1 or better. The required insurance shall be maintained at all times whi Proposer is providing service to County. I Statutory Limits Employers' Liability Insurance Bodily Injury by Accident $1,000,000 Bodily Injury by Disease, policy limits $1,000,000 Bodily Injury by Disease, each employee $1,000,000 Aft General Liability, including (0-�remises Operation Products and Completed Operations Vanket Contractual Liability Personal Injury Liability . . . . . . . . . . . . . ..... 1,11111 "11 1`1 Ili I I Till lri?� 11.0 .T* =.W41T;11 1! 1 1 !11111111 $500,000 per person WARN, 11M MOK11 K V Professional Liability $ 1, 000,00 0 per Occu rrence $2,000,000 Aggregate 0 ir-ri'tM*9F.r-F-rtV.*T,lri,MMiT-11 =A a 0 U. -■imlim. lffl� 61111 ;1IF■E i IIIIIIJFW I I I 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 Subcontractoll their officers, employees, servants or agents. 1"rIN1911MONOWN WOOM - W. low", el-1,111ell fallall plif .511 maintain me requIleup"ce, 1 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. WOURIJIll 1: QQ 21111). 61000121 Ill MIT-!& 6*9140 * .t ■ r- - ■ ■ ■ ■ ■ ■ ■ ■ ■, ■ r ■ ■ ■ fb agreed to by the Proposer. Yes, Can Comply but Yes No with Specified ServiceCan Cannot Deviations (please Comply Comply detail deviations below Utilize MCBCC Medical Plan document as basis for claims administration of Stop Loss claims. Provide prompt reimbursement of specific and aggregate claims. Provide estimated renewal rates 180 days in advance of renewal. Provide firm renewal rates 45 days in advance of renewal. Guarantee no lasers of individuals on renewal except at the specific request of MCBCC. Agree to provide either Specific Stop Loss, Aggregate Stop Loss, or both. ! All charges for any service or optional service must be clearly outlined in the pricing Attachment. No party to this Agreement shall be required to enter into any arbitration proceedings related to the A reement. I 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 CONTRACTOR may terminate this Agreement with ninety (90) days' notice to the COUNTY. The COUNTY may terminate this Agreement with or without cause upon thirty (30) days' notice to the CONTRACTOR. COUNTY ! shall pay CONTRACTOR for work performed through the date of termination. i Disclose any commissions and/or service fees that 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. Provide firm rates for the effective date of the policy based on the information provided in the RFP. Pursuant to Florida Statute §119.0701, Contractor and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: (a) Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement. (b) Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law. (c) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law. (d) Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the contractor upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from ' public records disclosure requirements. All records stored electronically must be provided to Monroe County in a format that is compatible with the information technology systems of Monroe County. The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions, Officers, and the Employees, and any other agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, attorney's fees, or liability of any kind arising out of the sole neg g� nt actions of the CONTRACTOR or substantial and unnecessary delay caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and answerable for any and all accidents or injuries to persons or property arising out of its performance of this contract. The amount and type of insurance coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs attendant to acts attributable to the sole negligent act of the CONTRACTOR. WIT RESPOND T T4' BOARD OF COUNTY COMMISSIONERSPurchasing Department GATO BUILDING, ROOM 2-213 1100 SIMONTON STREET KEY WEST, FLORIDA 33040 I have Included: • Response Form • Lobbying and Conflict of Interest Clause • Non -Collusion Affidavit • Drug Free Workplace Form 0 • Public Enfity Crime Statement • Copy of business tax receipt from the 0 Tax Collector's office • Local Preference Form (if applicable) 0 ,y (Title) STATE F: COUNTY F. +:-_ ii o me _: has produced identification. —NOTARYPUBLIC 3 �s ill � 012111142=1 umli F*IWITAMPRIVIRRO 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." Ws= I MOMMM MMOICAM Subscribed and swam to (or affirmed) before me on (date) by (name of fflant). He/ is personally known to me or has produced (type of identification) as identification ............................. NON -COLLUSION AFFID"IT 1, of the city of according to law on my oath, and under penalty of pedury, depose and say that 1 1 am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said proposal with full authority to do so; 2. The prices in this bid have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition; 5. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. COUNTY OF: M��� NOTARY PUBLIC I DRUG -FREE WORKPLACE FORM .............................................................................................. ............................................................................................................................... The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that: (Name of Business) ..... . . . . . . . FARAQ1,111 SIMON# Is 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 afflant). He/She is personally known to me or has produced (type of identification) as identificaticia NOTARY PL; "Ay Commission Expires: 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. BE= Date: 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: _ iial 'Milo 0,16019 L*j*11k1rf,T ,*1g,1P1j A m-, -Y tell - ffic- 111�lp lure]. -I d - Indemnification and hold harmless For 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 Contractors failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased ;nxpenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above, In 0111111 ME= VITEST. . 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 that - 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. GENERAL LIABILITY FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by is the Contractor shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: z Premises Operations Products and Completed Operations Blanket Contractual Liability Personal Injury Liability Expanded Definition of Property Damage -* =IMPAID. An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed an 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 liability policies issued to satisfy the above requirements. ENE 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. IIMFF%TLTM- 9 Mg- its M 1 111111 "&"-" Inis Patenlial anu acling on Ine duTice OF Ine County Commissioners has granted authorization to Risk Management to waive and modify various insurance provisions. The County as being named as an Additional Insured — If a letter from the Insurance Company (not the Agent) is presented, stating that they are unable or unwilling to name the County as an Additional Insured, Risk Management has not been granted the authority to waive this provision. 911111111111VAMWITMMMIM . , i - , 4, 17,1111:11MU 4 Waiving of insurance provisions could expose the Coun!y to economic loss. For this reason, every attempt should be made to obtain the standard insurance requirements. If a waiver or a modification is desired, a Request for Waiver of Insurance Requirement form should be completed and submitted for consideration with the proposal. After consideration by Risk Management and if approved, the form will be returned, to the County Attorney who will submit the Waiver with the other contract documents for execution by the Clerk of the Courts. Should Risk Management deny this Waiver Request, the other party may file an appeal with the County Administrator or the Board of County Commissioners, who retains the final decision -making authority. Request For Waiver of Insurance Requirements It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be waived or modified on the following contract: Contractor: Contract for: NIT MINIMIZE- lffmzff�!=� 231=W Risk Management: Date: County Administrator appeal: Approved Date: Board of County Commissioners appeal: Approved ZMLN� Ir =� SIGNATURE LOCAL PREFERENCE FORM A. Vendors claiming a local preference according to Monroe County 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 Runish 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 Countyl 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: WOMMM 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/ is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: BlueOptions 1w lenefit Booklet for Covered Plar "'articipants of Monroe County 'WOCC Group Health Plan A Self -funded Group Health Benefit Plan B0611 — 111113 Divisions 001, COI, ROI, ROZ, G02 Table of Contents Section 1: How to Use Your Benefit Booklet ...... ....... __ ... .......... ...... ........ 1-1 Section 2: What Is Covered?, .... ....... __ ....................... ...... ......... ...... 2-1 Section 3: What Is Not Covered? ... ......... ........... 3-1 Section 4: Medical Necessity ......... .............. ......... ........ 4-1 Section 5: Understanding Your Share of Health Care Expenses... .......... 6-1 Section 6: Physicians, Hospitals and Other Provider Options..... .... ......... ...... _ ....... 6-1 Section 7: BlueCard's (Out -of -State) Program ...... ......... ...... __ ..... 7-1 Section 8: Blueprint for Health Programs ............................................................... _ 8-1 Section 9: Pre-existing Conditions Exclusion Period ........ ...... _ ............................. _ 9-1 Section 10: Eligibility for Coverage, ........... ....... _ ....... ........ ..... ___ .... ........... ___ 10-1 Section 11 - Enrollment and Effective Date of Coverage ........................................ _.. 11 -1 Section 12: Termination of Coverage ........ ............. ................................................ 12-1 Section 13: Continuing Coverage Under COBRA .............. _ ........ ...................... 13-1 Section 14: Conversion Privilege.. .. . _... . ... ..................... ............. ......... ... A4-1 Section 15.- Extension of Benefits .... ............... .... _ ....... ........ __ ......... 15-1 Section 16: The Effect of Medicare over Medicare Secondary Payer Provisions ............. _ ............................. ...... ...... 16-1 Section 17: Duplication of Coverage Under Other Health Plan s/Programs ... _ - 17-1 Section 18- Subrogation .............................. ............ .... _ ........... ...... ............. 18-1 Section 19- Right of Reimbursement ............................... ........... 19-1 Section 20- Claims Processing ...................... ............ .......... ............ ... 20-1 Section 21 - Relationship Between the Parties ...... ___ .... _ ............. 21 -1 Section 22: General Provisions .............. __ .......... __ ........ ___ ...... ...... 22-1 Section 23: Definitions ........... ............... ...... ....... ....... ...... ...... 23-1 Table of Conlents I w I X This Is your Benefit Booklet ('Booklet"). It be coordinated with other policies or plans; describes your coverage, benefits, limitations and the Group Health Plan's subrogallon and exclusions for the self -funded Group Health rights and right of reimbursement. Benefit Plan ("Group Health Plan" or "Group You will need to refer to the Schedule of Plan') established and maintained by Monroe Benefits to determine how much you have to County BOCC. pay for particular Health Care Services. The sponsor of your Group Health Plan has contracted with Blue Cross Blue Shield of Florida, Inc. (BCBSF), under an Administrative Services Only Agreement ("ASO Agreement'), to provide certain third party administrative services, including claims processing, customer service, and other services, and access to certain of its Provider networks. BCBSF fi4 does not assume any financial risk or obligation Covered Persons or claims submitted for processing under this Benefit Booklet for such Services. The payment of claims under the Group Health Plan depends exclusively upon the funding provided by Monroe County BOCC. You should read your Benefit Booklet carefully before you need Health Care Services. It contains valuable information about: I, your SlueOpflons benefits; 81 what is covered, what is excluded or not covered; coverage and payment rules; Blueprint for Health Programs; how and when to file a claim; how much, and under what circumstances, payment will be made; what you will have to pay as your share; and How to Use Your Benefit Bookstit When reading your Booklet, please remember that: you should read this Booklet in its entirety in order to determine if a particular Health Care Service is covered. the headings of sections contained in this Booklet are for reference purposes only and shall not affect in any way the meaning or interpretation of particular provisions, references to 'you" or "your' throughout refer to you as the Covered Plan Participant and to your Covered Dependents, unless expressly stated otherwise or unless, In the context In which the term is used, it is clearly intended otherwise. Any references which refer solely to you as the Covered Plan Participant or solely to your Covered Dependent(s) will be noted as such. references to 'we', 'us", and 'o&'throughcut refer to Blue Cross and Blue Shield of Florida, Inc. We may also refer to ourselves as'BCBSF". if a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper name, a title, or a defined term. If the word or phrase has a special meaning, it will either be defined in the Definitions section or defined within the particular section where it is used. Where do you find information on........ 41 what particular types of Health Care Services are covered? Read the 'What Is Covered?" and "What Is Not Covered?" sections. 0 he much will be paid under your Group Health Plan and how much do you have to pay? Mead the "Understanding Tour IIII Share of Schedule of Benefits. how the amount you pay for Covered — Services under the BlueCard (Out -of - State) Program will be determined when you receive care outside the state of Florida? %ead the "BlueCard (Out -of -State) Program" cection. • how to add or remove a Dependent? Read the "Enrollment and Effective Date of Coverage" section. • what happens If you are covered under this Benefit Booklet and another health plan? Read the "Duplication of Coverage Under Other Health Plans Programs" section. • what happens when your coverage ends? it the 'Termination of Coverage" section. • what the terms used throughout this Booklet mean? Read the 'Definitions" section. Whenever you need cars, you have a choice. If you visit an: I In -Network Provider Out-of-ifletwork Provider n- W he ban We a ir k r Is er y Is 'a to u V is -Ne Hit Alder tWo PI DI -0 :f Is :t 0 You receive In -Network benefits, the You receive the Out -of -Network levei of s, is I 'a You Elevelof coverage available. You — you will share more of the cost of your care. You do not have to file a claim; the claim You may be required to submit a claim form. will be filed by the In -Network Provider for you. The In -Network Provider" is responsible You should notify BCBSF of inpatient for Admission Notification if you are admissions, admitted to the Hospital. notify us of inpatient admissions. How to Use Your Benefit Booklet 1.z Section 2: What Is Covered? MWI that aze_cnaxer_P_�ri r_tbLq_aeM4es benefits for Covered Services are subject to your share of the cost and the benefit maxi,= -ans bLe-d-an- ya-1 or SdtwdLdq_oLRe_rvsfiks,-- the applicable Allowed AmourrL any limitations and/or exclusions, as well as other provisions contained in this Booklet, and any Endorsemends) in accordance with BCBSF's guidelines then in effect. Remember that exclusions and limitations also apply to your coverage. Exclusions and limitations that are specific to a type of Service this section. Additional exclusions and limitations that may apply can be found in the 'What Is Not Covered?" section. More than one limitation or exclusion may apply to a specific Service or a particular situation. Expenses for the Health Care Services listed In this section will be covered under this Booklet only if the Services are: within the Health Care Services categories in the 'What Is Covered?" section: Z actually rendered (not just proposed or recommended) by an appropriately licensed health care Provider who is recognized for payment under this Benefit Booklet and for which an itemized statement or description of the procedure or Service which was rendered is received, including any applicable procedure code, diagnosis code and other information required In order to process a claim for the Service; 3. Medically Necessary, as defined in this Booklet and determined by BCBSF in accordance with BCBSF's Medical Necessity coverage criteria then in effect, except as specified in this section; 4. in accordance with the benefit guidelines listed below; S. rendered while your coverage is in force; and 6. not specifically or generally limited (e.g., Pre-existing Condition exclusionary period) or excluded under this Booklet. whIlllil gill ethL.r Services are Covered Services under this Booklet after you have obtained the Services and a claim has been received for the Service& In some circumstances BCBSF or Monroe County BOCC may determine whether Services might be Covered Services under this Booklet before you are provided the Service. For IDMIM1318- BOSSF or Monroe Cnuntv ROCC 111, 11411 � 41111 MCI matimmijiff-M transplant is provided. Neither BCBSF nor Monroe County BOCA are obligated to determine. in 2dvatce. whwthervng Se unless we have specifically designated that a Service is subject to a prior authorization requirement as described in the "Blueprint for Health Programs' section. We are also not obligated to cover or pay for any Service that has not actually been rendered to you. In determining whether Health Care Services are Covered Services under this Booklet, no written or verbal representation by any SOCC, or by any other person, shall waive or otherwise modify the terms of this Booklet and, therefore, neither you, nor any health care written or verbal representation, What Is Covered? 2.1 In providing benefits for Covered Services, the benefit guidelines listed below apply as well as any other applicable payment rules specific to particular categories of Services: 1 , Payment for certain Health Care Services is included within the Allowed Amount for the primary procedure, and therefore no additional amount is payable for any such Services. Z Payment is based on the Allowed Amount for the actual Service rendered (i.e., payment Is not based on the Allowed Amount for a Service which is more complex than that actually rendered), and is not based on the method utilized to perform the Service or the day of the week or the time of day the procedure is performed. 1 Payment for a Service includes all components of the Health Care Service when the Service can be described by a single procedure code, or when the Service Is an essential or Integral part of the associated therapeutic/diagnostic Service rendered. Accident Care Health Care Services to treat an Injury or illness resulting from an Accident not related to your job or employment are covered. Exclusion: Health Care Services to treat an injury or illness resulting from an Accident related to your job or employment are excluded. Allergy Testing and Treatments Testing and desensitization therapy (e.g.. injections) and the cost of hyposensifization serum are covered. The Allowed Amount for allergy testing is based upon the type and number of tests performed by the Physician. .REEDVie. Ambulance Services provided by a ground to transport you from: NINNIM 2. a Hospital to your nearest home, or to a Skilled Nursing Facility; or 3. the place a medical emergency occurs to the nearest Hospital that can provide proper care. Expenses for Ambulance Services by boat, airplane, or helicopter shall be limited to the Allowed Amount for a ground vehicle unless: 1. the pick-up point is inaccessible by ground vehicle; 2. speed in excess of ground vehicle speed Is critical; or t-- the travel distance involved In getting you ff the nearest Hospital that can provide proper care is too far for medical safety, as determined by BCBSF or Monroe County BOCC. D -day maximums for ground transportation er and airlwater transportation, Ambulatory Surgical Centers Health Care Services rendered at an Ambulatory Surgical Center are covered and include: 1. use of operating and recovery rooms; 2. respiratory, or inhalation therapy {e.g., oxygen); What Is Covered? 2-2 3. drugs and medicines administered (except for lake home drugs) at the Ambulatory Surgical Center, 4. intravenous solutions-, 5. dressings, including ordinary casts; 6. anesthetics and their administration; 7. administration of, including the cost of, whole blood or blood products (except as outlined in the Drugs exclusion of the 'What Is Not Covered?" section); S. transfusion supplies and equipment; 9. diagnostic Services, Including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG); and 10. chemotherapy treatment for proven malignant disease. Anesthesia Administration Services Administration of anesthesia by a Physician or may be covered. In those instances where the CRNA is actively directed by a Physician other then the Physician who perfortned the surgical me DOy n N b A in a c 'a v c a Phy It r v a I a c d '1Y d n In w th c t he a P a d a Is in y starts Phy 7ha e as �s a as a ad t a 'as w to a he n r 0 a I In Z� r dorm, he surgical procedure, payment for Covered Services, if any, will be made for both the CRNA and the Physician Health Care Services at the lower a j with BCBSFA payment program then in effect N for such Covered Services. Coverage does not include anesthesia Services by an operating Physician, his or her partner or associate, Autism Spectrum Disorder Autism Spectrum Disorder Services provided to a Covered Dependent who Is under the age of 18, or if 18 years of age or older, is attending high school and was diagnosed with Autism Spectrum Disorder prior to his or her e birthday consisting of-. 393.17 of the Florida Statutes or licensed under Chapters 490 or 491 of the Florida Statutes; and 3. Physical Therapy by a Physical Therapist, Occupational Therapy by an Occupational Therapist, and Speech Therapy by a Speech Therapist. Covered therapies provided in the treatment of Autism Spectrum Disorder are covered even though they may be habilitative in nature (provided to teach a function) and are not necessarily limited to restoration of a function or skill that has been lost. wf.. � I I A. ............ of Autism Spectrum Disorder outlined in paragraph three above will be applied to the Outpatient Therapies Benefit Period maximum set forth in the Schedule of Benefits. Autism before such Services are rendered. Services performed without authorization will be denied. of an Emergency Medical Condition. Any Services for the treatment of Autism 0her-ithain as-w&eftall`y identified as covered in this section. Rote: In order to determine whether such Awfism Siptetrurn III Visorder Sisprices are c*vdreC under this Benefit Booklet, we reserve the right 41 by the treating Physician to include the diagnosis, the proposed treatment type, the frequency and duration of treatment, the Whale ts covered? 2-3 anticipated outcomes stated as goals, and the frequency with which the treatment plan will be updated, but no less than every 6 months. This benefit booklet will only cover services to the extent included In the Treating Physician's formal written treatment plan. Breast Reconstructive Surgery Surgery to reestablish symmetry between two breasts and implanted prostheses incident to Mastectomy is covered. In order to be covered, such surgery must be provided in a manner chosen by your Physician, consistent with prevailing medical standards, and in consultation with you. Child Cleft Lip and Cleft Palate Treatment Treatment and Services for Child Cleft Lip and Cleft Palate, including medical, dental, Speech Therapy, audiology, and nutrition Services for treatment of a child under the age of 18 who has cleft lip or cleft palate are covered. In order for such Services to be covered, your Covered Dependent's Physician must specifically prescribe such Services and such Services must be medically necessary and consequent to treatment of the cleft lip or cleft palate. Concurrent Physician Care Concurrent 161hysician care Services are covered, provided: (a) the additional Physician actively participates in your treatment; (b) the Condition involves more than one body system or Is so severe or complex that one Physician Consultations provided by a Physician are covered if your attending Physician requests the consultation and the consulting Physician prepares a written report, immm.: X the medication and administration when medically necessary. Dental Services Dental Services are limited to the following: 1 . Care and stabilization treatment rendered within 90 days of an Accidental Dental Injury to Sound Natural Teeth. 2. Extraction of teeth required prior to radiation therapy when you have a diagnosis of cancer of tie keadfatrVor neck. 1 Anesthesia Services for dental care including general anesthesia and hospitalization Services necessary to assure the safe delivery of necessary dental care provided to you or your Covered Dependent in a Hospital or Ambulatory Surgical Center a) the Covered Dependent is under 8 years of age and it is determined by a dentist and the Covered Dependent's Physician that: 1. dental treatment is necessary due to a dental Condition that is significantly complex; or 1L the Covered Dependent has a developmental disability In which patient management in the dental office has proven to be ineffective; or b) you or your Covered Dependent have one or more medical Conditions that would create significant or undue medical risk for you in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or Ambulatory Surgical Center. What Is CovereV 2-4 Dental Services provided more than 90 days after the date of an Accidental Dental Injury regardless of whether or not such services could have been rendered within 90 days; and 2. Dental Implant. Diabetes Outpatient Self -Management Diabetes outpatient self -management training and educational Services and nutrition counseling (including all Medically Necessary equipment and supplies) to treat diabetes, if your treating Physician or a Physician who specializes in the treatment of diabetes certifies that such Services are Medically Necessary, are covered. In order to be covered, diabetes outpatient self -management training and educational Services must be provided under the direct supervision of a certified Diabetes Educator or a board -certified Physician specializing in endocrinology. Additionally, in order to be covered, nutrition counseling must be provided by a licensed Dietitian, Covered Services may also include the trimming of toenails, come, calluses, and therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease, Diagnostic Services Diagnostic Services when ordered by a Physician are limited to the following: 1. radiology, ultrasound and nuclear medicine, Magnetic Resonance Imaging (MI); Z laboratory and pathology Services; 3. Services involving bones or joints of the jaw (e.g., Services to treat temporomandibular joint [TMJ] dysfunction) or facial region if, under accepted medical standards, such diagnostic Services are necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury; 4. approved machine testing electrocardiogram (EKG], electroencephalograph [EEG], and other electronic diagnostic medical procedures)' aid I possible hereditary disease, 11"Irt and medical supplies, when provided at any location by a Provider licensed to perform IN.T. WW WIMEM1711 prescribed by a Physician, limited to the most cost-effective equipment as determined by BCBSF or Monroe County BODO is covered. rzrw Supplies and service to repair medical own the equipment or you are purchasing the equipment. Payment for Durable Medical Equipment will be based on the lowest of the following: 1) the purchase price-, 2) the Allowed Amount. The Allowed Amount for such rental equipment will not exceed the total purchase price. Durable Medical Equipment includes, but is not limited to, the following: wheelchairs, crutches, canes, walkers, hospital Ante. Repair or replacement of Durable significant change in functional status is a Covered Service. Equipment which is primarily for convenience What Is Covered? 2-5 and/or homes, including but not limited to, wheelchair lifts or ramps; water therapy devices such as JacuMs, hot tubs, swimming pools or whirlpools; exercise and message equipment, electric scooters, hearing aids, air conditioners and purifiers, humidifiers, water softeners and/or purifiers, pillows, mattresses or waterbeds, escalators, elevators, stair glides, emergency alert equipment, handrails and grab bars, heat appliances, dehumidifiers, and the replacement of Durable Medical Equipment solely because it is old or used are excluded. Emergency Services Emergency Services for an Emergency Medical Condition are covered when rendered In - Network and Out-ol-Network without the need For any prior authorization determination by us. When Emergency Services and care for an Emergency Medical Condition are rendered by an Out-of-pletwork Provider, any Copayment and/or Coinsurance amount applicable to In - Network Providers for Emergency Services will also apply to such Out-of-pletwork Provider. Sgecial PaSigent Rules for Non-Grandfathered Mans The Patient Protection and Affordable Care Act (PPACA) requires that non-grandfathered health plans apply a specific method for determining the allowed amount for Emergency Services rendered for an Emergency Medical Condition by Providers who do not have a contract with us. Payment for Emergency Services rendered by an Out-of-pletwork Provider that has not entered into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider will be the greater of. 1. the amount equal to the median amount negotiated with all BCBSF In -Network Providers for the same Services', 1 the Allowed Amount as defined in the Booklet; 3, the usual and customary Provider charges for similar Services in the community where the Services were provided; or 4. what Medicare would have paid for the Services rendered. In no event will Out -of -Network Providers be paid more than their charges for the Services rendered. Prescription and non-prescription enteral forrmfias for home use when prescribed by a Physician as necessary to treat inherited diseases of amino acid, organic acid, carbohydrate or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period are covered. Coverage to treat inherited diseases of amino acid and organic acids, for you up to your 251h birthday, shall include coverage for food products modified to be low protein. Eye Care Coverage Includes the followingServices: 1. Physician Services, soft lenses or asters shells, for the treatment of aphakic patients; 2. initial glasses or contact lenses following cataract surgery; and 3. Physician Services to treat an injury to or disease of the eyes, Health Care Services to diagnose or treat vision problems which are not a direct consequence of trauma or prior ophthalmic surgery; eye examinations; eye exercises or visual training; eye glasses and contact lenses and their fitting are excluded. In addition to the above, any surgical procedure performed primarily to correct or Improve myopia or other refractive disorders W,g., radial keratecerry, PRK and LASIK) are excluded, What Is Covered? 2-6 IMMMUMMIMM The Home Health Care Services listed below are covered when the following criteria are met: 1. you are unable to leave your home without considerable effort and the assistance of another person because you are: bedridden or chairbound or because you are restricted In ambulation whether or not you use assistive devices; or you are significantly limited In physical activities due to a Condition; and 2. the Home Health Care Services rendered have been prescribed by a Physician by way of a formal written treatment plan that has been reviewed and renewed by the prescribing Physician every 30 days, In order to determine whether such Services are covered under this Booklet, you may be required to provide a copy of any written treatment plan; 3. the Home Health Care Services are provided directly by (or indirectly through) a Home Health Agency; and 4. you are meeting or achieving the desired treatment goals set forth in the treatment plan as documented in the clinical progress notes. Home Health Care Services are limited to: I. part-time (i.e., less than 8 hours per day and less than a total of 40 hours in a calendar week) or intermittent (i.e., a visit of up to, but not exceeding, 2 hours per day) nursing care by a Registered Nurse, Licensed Practical Nurse and/or home health aide Services, 2. home health aide Services must be consistent with the plan of treatment, ordered by a Physician, and rendered under the supervision of a Registered Nurse; 3. medical social services; 4. nutritional guidance; 5. respiratory, or Inhalation therapy (e.g., oxygen); and 6. Physical Therapy by a Physical Therapist, Occupational Therapy by a Occupational Therapist, and Speech Therapy by a Speech Therapist. ■ HERITANTIM-W ■ 3. Services rendered by an employee or operator of an adult congregate living facility; an adult foster home; an adult day care center, or a nursing home facility; 4. Speech Therapy provided for a diagnosis of K.elopmental delay; 5. Custodial Care except for any such care covered under this subsection when provided on a part-time or intermittent basis (as defined above) by a home health aide; 6. food, housing, and home delivered meals; and 7. NII Services rendered in a Hospital, nursing home, or intermediate care facility, . . . . . . . ..... . . . . . . with a Jl Hospice treatment program may be Covered Services, provided the Hospice treatment program is: 10M MR. In 1. room and board in a seml-private room when confined as an Inpatient, unless the patient must be isolated from others for documented clinical reasons; What Is Covemd? 2-7 1 Intensive care units, including cardiac, progressive and neonatal care; 1 use of operating and recovery roams; 4. use of emergency rooms; 5e respiratory, pulmonary, or inhalation therapy (e.g., oxygen); 6. drugs and medicines administered (except for take home drugs) by the Hospital; 7. intravenous solutions-, 8. administration of, including the cost of, whole blood or blood products except as outlined in the Drugs exclusion of the "What Is Not Covered?" section); 9. dressings, including ordinary casts; 10. anesthetics and their administration; M transfusion supplies and equipment; 12. diagnostic Services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG); 11 Physical, Speech, Occupational, and Cardiac Therapies; and 14. transplants as described in the Transplant Services subsection. Exclusion: Expenses for the following Hospital Services are excluded when such Services could have been provided Without admitting you to the Hospital: 1) room and board provided during the admission; 2) Physician visits provided while you were an inpatient; 3) Occupational Therapy, Speech Therapy, Physical Therapy, and Cardiac Therapy; and 4) other Services provided while you were an Inpatient. In addition, expenses for the following and similar items are also excluded: 1. gowns and slippers; 2. shampoo, toothpaste, body lotions and hygiene packets; 3. take-home drugs; 4. telephone and television; 5. guest meals or gourmet menus; and 6. admission kits, a a A it A M excluded. What Is Covered? 2-8 Mammograms obtained in a medical office, medical treatment facility or through a health testing service that uses radiological equipment agencies (or those of another state) for diagnostic purposes or breast cancer screening are Covered Services. . .. . ..... .. ..... ..... ... .. . the Deductible, Coinsurance, or Copayment (if applicable). Please refer to your Schedule of Benefits for more information. ........... (including lymphedemas), and outpatient post - medical standards as determined by you and your attending Physician are covered. Outpatient post -surgical follow-up care for Mastactomy Services shall be covered when provided by a Provider in accordance with the prevang medical standards and at the most medically appropriate setting. The setting may be the Hospital, Physician's office, outpatient center, or your home, The treating Physician, after consultation with you, may choose the appropriate setting. Maternity Services Health Care Services, including prenatal care, delivery and postpartum care and assessment, pzbmblacOin e nt n 11mrfor of Medicine i hv Doctor of Osteopathy (D.O.), Hospital, Birth r_&mter_NdW be Covered Services. Care for the mother includes the postpartum assessment. In order for the postpartum assessment to be a Hospital, an attending Physician's office, an i. qualified licensed health care professional trained in care for a mother. Coverage under this Booklet for the postpartum assessment Includes coverage for the physical assessment keeping with prevailing medical standards. Under Federal law, your Group Plan generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery; or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newbom's attending Provider, after cojrsuft[*q wific t4w inmIter, fromi dischar 96 as applicable). In any case, under Federal law, your Group Plan can only require that a provider obtain authorization for prescribing an . . . . . . . . . . . . . . . . . . . ..... . . . . . . Maternity Services rendered to a Covered Ru trigale-u -.Eda with, a Gestational Surrogacy Contract or Arrangement are excluded. This exclusion applies to all expenses for prenatal, intra-parm and post-partal Maternity/Obstetrical Care, an Health Care Services rendered to the Covered Person acUng as a Gestational Surrogate. Gestational Surrogacy Contract, see the "Definitions" section of this Benefit Booklet. Physician -administered Prescription Drugs which are rendered in a Physician's office are tilt. The Medical Pharmacy Cost Share amount applies to the Prescription Drug and does not Include the administration of the Prescription Drug. What 15 Co 2.9 Pharmacy. If your plan includes a Medical Pharmacy out-of-pocket monthly maximum, it will be listed on your Schedule of Benefits and if applicable. Please refer to your Schedule of Benefits for the additional Cost Share amount and/or monthly maximum out-of-pocket applicable to Medical Pharmacy for your plan. Note: For purposes of this benefit, allergy injections and immunizations are not considered Medical Pharmacy. Diagnostic evaluation, psychiatric treatment, individual therapy, and group therapy provided to you by a Physician, Psychologist, or Mental i and Nervous Disorder may be covered, These Health Care Services include inpatient, outpatient, and Partial Hospitalization services. Partial Hospitalization is a Covered Service when provided under the direction of a Physician and in lieu of inpatient hospitalization. 1. Services rendered in connection with a Condition not classified in the diagnostic categories of the International Classification of Diseases, Ninth Edition, Clinical Modification (ICO-9 CM) or their equivalents In the most recently published version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, regardless of the underlying cause, or effect, of the disorder; 2. Services for psychological testing associated with the evaluation and diagnosis retardation-, 4. Services for marriage counseling, when not rendered In connection with a Condition classified in the diagnostic categories of the International Classation of Diseases, Ninth Edition, Clinical Modcation fiCD-9- CM) or their equivalents in the most recently published version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders; probation; 7. Services foiiii r testing of aptitude, ability, intelligence or interest (except as covered under the Autism Spectrum Disorder subsection); 8. Services for testing and evaluation for the purpose of maintaining employment; 9. Services for cognitive romediation; 10inpatient confinements that are primarily intended as a change of environment; or jjL-L*PAtjAOj4OMP-LA1Qnk1 UIRLARRUk received in a residential treatment facility. Newborn Care A newborn child will be covered from the is eligible for coverage and property enrolled. Covered Services shall consist of coverage for in or sickness, including the necessa* care or treatment of medically diagnosed congenital . ........... AREM ........... i .. , ............. . ... provided the Services were rendered at a What Is covered? 2-I0 Hospital, the attending Physician's office, a Birth Center, or in the home by a Physician, Midwife or Certified Nurse Midwife, and the performance of any necessary clinical tests and immunizations are within prevailing medical standards. These Services are not subject to the Deductible. Ambulance Services, when necessary to transport the newborn child to and from the nearest appropriate facility which is staffed and equipped to treat the newborn child's Condition, as determined by BCSSF or Monroe County BOCC and certified by the attending Physician as Medically Necessary to protect the health and safety of the newborn child, are covered. Under Federal law, your Group Plan generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery; or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 as applicable). In any case, under Federal law, your Group Plan can only require that a provider obtain authorization for prescribing an inpatient hospital stay that exceeds 48 hours (or 96 hours). Orthotio Devices including braces and trusses for the leg, arm, neck and back, and special surgical corsets are covered when prescribed by a Physician and designed and fitted by an Orthotist. Benefits may be provided for necessary replacement of an Orthotic Device which is owned by you when due to irreparable damage, wear, a change in your Condition, or when necessitated due to growth of a child. Payment for splints for the treatment of temporomandibular joint ('TMJ") dysfunction is limited to payment for one splint in a six-month period unless a more frequent replacement Is VOCI; to be Medically Necessary. oil= 1. Expenses for arch supports, shoe inserts designed to effect conformational changes in the foot or foot alignment, orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, ready- made compression hose or support hose, or similar type deviceslappliances regardless of Intended use, except for therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease; 2. Expenses for orthofic appliances or devices which straighten or re -shape the conformation of the head or bones of the skull or cranium through cranial banding or molding (e.g. dynamic orthofic cranioplasty or molding helmets), except when the orthotic appliance or device is used as an alternative to an internal fixation device as a result of surgery for craniosynostosis; and 3. Expenses for devices necessary to exercise, train, or participate in sports, e.g. custom- made knee braces. 4 . Treatment Screening, diagnosis, and treatment of 15"C as medically necessary, including, but not Rini tied to: 13�;Vll clinical risk for osteoporosis, ffi-iffll�qa- �m._ What Is Covered? 2-11 4. individuals who have primary hyperparathyroldism, and 5. individuals who have a family history of asteoponeds, low Speech, Massage Therapies and Spinal Manipulation Services Outpatient therapies listed below may be Covered Services when ordered by a Physician or other health care professional licensed to perform such Services. The outpatient therapies listed in this category are In addition to the Cardiac, Occupational, Physical and Speech Therapy benefits listed In the Home Health Care, Hospital, and Skilled Nursing Facility categories herein. Cardiac Therapy Services provided under the supervision of a Physician, or an appropriate Provider trained for Cardiac Therapy, for the purpose of aiding in the restoration of normal heart function in connection with a myocardial infarction, coronary occlusion or coronary bypass surgery are covered. Occupational Therapy Services provided by 5 Physician or Occupational Therapist for the purpose of aiding in the restoration of a previously impaired function lost due to a Condition are covered. Speech Therapy Services of a Physician, Speech Therapist, or licensed audiologist to aid in the restoration of speech loss or an impairment of speech resulting from a Condition are covered. Physical Therapy Services provided by a Physician or Physical Therapist for the purpose of aiding in the restoration of normal physical function lost due to a Condition are covered. Massage Therapy Massage provided by a Physician, Massage Therapist, or Physical being Medically Necessary by a Physician 458 (Medical Practice), Chapter 459 Chapter 461 (Podiatry) is covered. The Physician's prescription must specify the number of treatments. Physical Thera2.y .. ...... "M7� limited to no more than four (4) 15-minut the Outpatient Cardiac, Occupational, : Physical, Speech, and Massage Therapi mW.X listed on the Schedule of Benefits. Z Payment for a combination of covered Massage and III Physical Therapy Services rendered on the same day is limited to no more than four (4) 15-minute treatments per day for combined Massage and Physical Therapy treatment, not to exceed the Outpatient Cardiac, Occupational, Physical, Speech, and Massage Therapies and Spinal Manipulations benefit maximum listed on the Schedule of Bevetits. 3. Payment for covered Physical Therapy Services rendered on the same day as spinal manipulation Is limited to one (1) Physical Therapy treatment per day not to exceed fifteen (115) minutes in length. . . . . . . . . . . . . Bum dislocation of a bone orjoint that is demonstrated by x-ray are covered. 1. Payment for covered spinal manipulation is limited to no more than 26 spinal manipulations per Benefit Period, or the maximum benefit listed in the Schedule of s. I 2. Payment for covered Physical Therapy Services rendered on the same day as Q spinal manipulation is limited to one (1) What Is Covenstr? 2-12 Physical Therapy treatment per day, not to exceed fifteen (15) minutes in length. Your Schedule of Benefits sets forth the maximum number of visits covered under this plan for any combination of the outpatient therapies and spinal manipulation Services listed above. For example, even if you may have only been administered two (2) of the spinal manipulations for the Benefit Period, any additional spinal manipulations for that Benefit Period will not be covered if you have already met the combined therapy visit maximum with other Services. Oxygen Expenses for oxygen, the equipment necessary to administer it, and the administration of oxygen are covered. Physician Services Medical or surgical Health Care Services provided by a Physician, including Services rendered in the Physician's office, in an outpatient facility, or electronically through a computer via the Internet. Priament Guidelines for Physician Services Provided by Electronic Means through Coffifiligtor Expenses for online medical Services provided via the Internet will be covered only if such Services: were provided to a covered individual who was, at the time the Services were provided, an established patient of the Physician rendering the Services; 2. were in response to an online inquiry received through the Internet from the covered individual with respect to which the Services were provided; and 3. were provided by a Physician through a secure online healthcare communication services vendor that, at the time the Services were rend was under contract with BCBSF, flisnea oaffMr, shall mean that the covered individual has received professional services from the Physician who provided the online Imedical Services, or another physician of the same specla4 who belongs to the same group practice as that ithysician, within the past thr years. R�_Iil Expenses for online medical Services provided electttrika4y4hrouth a o5mpabor iy a Phyi4esaia via the Internet other than through a healthcare into contract with BCBSF are excluded. Expenses for online medical Services provided by a health care provider that Is not a Physician and expenses for Health Care Services rendered by telephone are also excluded. 'WrTunyr 405 sul A and children based on prevailing medical standards and recommendations which are explained further below. Some examples of preventive health Services include, but are not lin,fted in- Uerks.0jr: ntutdro INaafti, exQns. mud io WWRIURM preventive Services such as Prostate Specific Antigen (PSA), routine mammograms and pap smears. In order to be covered, Services shall be provided in accordance with prevailing medical standards consistent with: I. evidence -based items or Services that have in effect a rating of 'A' orB' in the current recommendations of the U.S. Preventive Services Task Force established under the Public Health Service Act; recommendation from the Advisory What Is Covered? 2.13 Centers for Disease Control and Prevention established under the Public Health Service Act with respect to the individual involved; 1 with respect to infants, children, and adolescents, evidence- Informed preventive care and screenings provided for In the comprehensive guidelines supported by the Health Resources and Services Administration; and 4, with respect to women, such additional preventive care and screenings not described in paragraph number one as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. Women's preventive coverage under this category Includes, a. well -woman visits; tt, screening for gestational diabetes; c. human papillomavirus testing; it. counseling for sexually transmitted infections', a. counseling and screening for human immune -deficiency virus; L contraceptive methods and counseling; g, screening and counseling for interpersonal and domestic violence; and h. breastfeeding support, supplies and counseling. Breaeffeeding supplies are limited to one manual breast pump per pregnancy. Exclusion: Routine vision and hearing examinations and screenings are not covered, except as required under paragraph number one above. Sterilization procedures covered under this section are limited to must ligations only. Contraceptive Implants are limited to mire- lamIlT.M., f MKO, M-1., and fitted by a Prosthatist: 1 . artificial hands, antis, feet, legs and eyes, Including permanent Implanted lenses following cataract surgery, cardiac pacemakers, and prosthetic devices incident to a Mastectomy; 2. appliances needed to eftectively use artificial limbs or corrective braces', or Mastectomy) are limited to the first such permanent prosthesis (including the first temporary prosthesis if it is determined to be necessary) prescribed for each specific Condition. Benefits may be provided for necessary replacement of a Prosthetic Device which is wear, or a change in your Condition, or when necessitated due to growth of a chlld 2. Expenses for cosmetic enhancements to artificial limbs. ... . i �1 � . 11, r . M� .. . . M'r 1. Self -Administered Prescription Drugs used in the treatment of diabetes, cancer, Conditions requiring immediate stabllization What Is CoverW17 2-14 (e.g. anaphylaxis), or in the administration of dialysis; and 2. Self -Administered Prescription Drugs identified as Specialty Drugs with a special symbol in the Medication Guide when delivered to you at home and purchased at a Specialty Pharmacy or an Out -of -Network Provider that provides Specialty Drugs. 3. Specialty Drugs used to increase height or bone growth (e.g., growth hormone), must meet the following criteria in order to be covered: a. Must be prescribed for Conditions of growth hormone deficiency documented with two abnormally low stimulation tests of less than 10 nghm and one abnormally low growth hormone dependent peptide or for Conditions of growth hormone deficiency associated with loss of pituitary function due to trauma, surgery, tumors, radiation or disease, or for state mandated use as in patients with AIDS. b. Continuation of growth hormone therapy is only covered for Conditions associated with significant growth hormone deficiency when there is evidence of continued responsiveness to treatment. Treatment Is considered responsive in children less than 21 years of age, when the growth hormone dependent peptide hGF-1) is In the normal range for age and Tanner development stage-, the growth velocity is at least 2 cm per year, and studies demonstrate open epiphyses. Treatment is considered responsive in both adolescents with closed epiphyses and for adults, who continue to evidence growth hormone deficiency and the I G F- 1 remains in the normal range for age and gender. The following Health Care Services may be Covered Services when you are an Inpatient In a Skilled Nursing Facility: 1. room and board; 1 respiratory, pulmonary, or inhalation therapy (e.g,, oxygen); 3. drugs and medicines administered while an inpatient (except take home drugs); 4, intravenous solutions; 5. administration of, including the cost of, whole blood or blood products(except as outlined In the Drugs exclusion of the'What Is Not CovereI section); S. dressings, including ordinary casts; 7. transfusion supplies and equipment; S. diagnostic Services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG),, 9. chemotherapy treatment for proven malignant disease-, and 10. Physical, Speech, and Occupational Therapies. A treatment plan from your Physician may be required in order to determine coverage and payment. Exclusion: Nursing Facty for purposes of Custodial Care, convalescent care, or any other Service family members or the Provider are excluded. What Is Covered? 2.15 Mental Health Professional in a program accredited by the Joint Commission an the state) for Detoxification or Substance Dependency. 2. Physician, Psychologist and Mental Health Professional outpatient visits for the care and treatment of Substance Dependency. IM9 Substance Dependency in a specialized inpatient or residential facility or inpatient **WW change of environment are excluded. Surgical Assistant Services Services rendered by a Physician, Registered Nurse First Assistant or Physician Assistant when acting as a surgical assistant (provided no intern, resident, or other staff physician is available) when the assistant is necessary are covered. Surgical Procedures Surgical procedures performed by a Physician may be covered including the following: 1. sterilization (must ligations and vasectomies), regardless of Medical Necessity; 2. surgery to correct deformity which was caused by disease, trauma, birth defects, growth defects or prior therapeutic Now&= 3, oral surgical procedures for excisions of tumors, cysts, abscesses, and lesions of the mouth; 4, surgical procedures Involving bones or joints of the law (e.g., temporomandibular joint [TMJj) and facial region If, under accepted medical standards, such surgery is necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury; 6. Services of a Physician for the purpose of rendering a second surgical opinion and related diagnostic services to help determine the need for surgery; and & surgical procedures performed on a Covered Plan Participant for the treatment of Morbid Obesity (e.g., intestinal bypass, stomach stapling, balloon dilation) and the associated care provided the Covered Plan Participant has not previously undergone the same or similar procedure In the lifetime of this Group Health Plan when medically necessary. Exclusion: & Surgical procedures for the treatment of Morbid Obesity including: intestinal bypass; stomach stapling; balloon dilation and associated care for the surgical treatment of Morbid Obesity, if the Covered Plan Participant has previously undergone the same or similar procedures in the lifetime of this Group Health Plan. Surgical procedures performed to revise, or correct defects related to, a prior intestinal bypass, stomach stapling or balloon dilation are also excluded. Id. Reversal of a weight loss surgery, surgical procedures to revise, correct and correction of defects to include adjustment to devices implanted or a fills not performed during the initial surgical event. I Payment for multiple surgical procedures irocedure, in t same or different areas of will be based on 50 percent of the Allowed Amount for any secondary surgical procedure(s) performed. In addition, What is Covered? 2.16 In your Schedule of Benefits will apply. This guideline is applicable to all bilateral procedures and all surgical procedures performed on the same date of service. 2, Payment for incidental surgical procedures Is limited to the Allowed Amount for the primary procedure, and there is no additional payment for any incidental procedure. An "Incidental surgical procedure" includes surgery where one, or more than one, surgical procedure is performed through the same incision or operative approach as the primary surgical procedure which, in F's or Monroe County 's opinion, Is not clearly identified and/or does not add significant time or complexity to the surgical session. For example, the removal of a normal appendix performed in conjunction with a Medically Necessary hysterectomy is an incidental surgical procedure (i.e., there Is no payment for the removal of the normal appendix in the example). 3. Payment for surgical procedures for fracture care„ dislocation treatment, debridement, wound repair, unna besot, and rather related Health Care Services, is included in the Allowed Amount of the surgical procedure. Transplant Services Transplant Services, limited to the procedures a facility acceptable to BCBSF or Monroe County BOCC, subject to the conditions and limitations described below. Transplant includes pre -transplant, transplant and past -discharge Services, and treatment of complications after transplantation. Benefits will only be paid for Services, care and treatment received or provided in connection with a: 1. Bone Marrow Transplant, as defined herein„ which is specifically listed in the rule 5913- 12.001 of the Florida Administrative Code or describedany successor or similar rule or covered by Medicare as published Medicare a E e Issues expensesand Medicaid Services. Coverage will be provided for the expenses incurred for the donation of bone marrow by a donor to the same extent such obe covered for you and will be subject to the applicable to you. Coverage for the reasonable expenses donor immediate family members and donors Donor Pro bridge to heart transplantation); 5. liver transplant; ■. e lung -whole :. Coverage be ■ provided ..,E I ■ dcostsorgan ■ I III !� III acquisition"for transplants, Bone Marrow Transplants, provided such cc instrance carrier, 4 f.. F # 1717 than etestate. You may call the customer service phone number indicated In this Booklet your .-�* deaw-Mina wit eh Bone Marrow Transplants are covered under this Booklet What 1s `3 2-17 Expenses for the following are excluded: 1. transplant procedures not included in the list above, or otherwise excluded under this Booklet (e.g., Experimental or Investigational transplant procedures); 2. transplant procedures involving the transplantation or Implantation of any non- human organ or tissue; 3. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered under this Benefit Booklet; 4. transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ; 5. any organ, tissue, marrow, or stem calls which is/are sold rather than donated; 6, any Bone Marrow Transplant, as defined herein, which is not specifically listed in rule 5913-12.001 of the Florida Administrative Code or any successor or similar rule or covered by Medicare pursuant to a national coverage decision made by the Centers for Medicare and Medicaid Services as evidenced in the most recently published Medicare Coverage Issues Manual; 7. any Service in connection with the Identification of a donor from a local, state or national listing, except in the case of a Bone Marrow Transplant; 8. any non -medical costs, including but not limited to, temporary lodging or transportation costs for you and/or your family to and from the approved facility; and 9. any artificial heart or mechanical device that replaces either the atrium and/or the ventricle, What Is Coyered? 2-18 Your Booklet expressly excludes expenses for the following Health Care Services, supplies, drugs or charges. The following exclusions are in addition to any exclusions speced in the 'Whsittweumart ?L-s actisrr*rwV�sth ama of the Booklet. FTMNMT��� conformations] changes In the foot or foot alignment, orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, ready-made compression hose or m"or-who-v-v, or smAar regardless of intended use, except for diabetic foot disease. R. 73 supplies, and medications for In Vitro Fertilization qVF); Gamete Intraftalopian Transfer (GIFT) procedures; Zygote Intrafallopoin Transfer (ZIFT) procedures; Artificial Insemination IV); embryo transport; surrogate parenting; donor semen and related costs including collection and preparation; and infertility treatment medication. T 15TTIUMV7, unless speccally requested by BCBSF or Monroe County BOCC. Ayurvedic medicine such as lifestyle modifications and purification therapies; traditional Oriental medicine including acupuncture; naturopathic medicine; clinical ecology, chelation therapy; thermography; mind -body interactions such as meditation, imagery, yoga, dance, and art therapy; blofeedback; prayer and mental healing; manual healing methods such as the Alexander technique, aromatherapy, Ayurvedic massage, crankenscral balancing, Feldenbrais method, Hellerwork, polarity therap., Reichian therapy, reflevology, roffing, shlatsu. traditional myotherapy, and Moffeld therapeutics; Relld, SHEN therapy, and therapeutic touch; herbal therapies. Complications of Non -Covered Services, including the diagnosis or treatment of any Condition which is a complication of a non- - R Q #%� r.=r= carsArg Services to treat a complication of cosmetic surgery are not covered). Contraceptive medications, devices, QW49A �— provided for contraception, except when Indicated as covered, under the Preventive Health Services category of the 'What Is Covered?" section, Cosmetic Services, including any Service to individual (except as covered under the Breast 440UQ��,� w without limitation: cosmetic surgery and procedures or supplies to correct hair loss or skii. wrizidirg W.g—Wirwitil, Ro,1--imie, Reflr,-A-�, and hair implants/transplants. nature, including and without limitation: Health What Is Not covered? 3-1 of daily living; rest homes; home companions or sitters; home parents; domestic maid services; respite care; and provision of services wh1ch are for the sole purposes of allowing a family member or caregiver of a Covered Person to return to work. Dental Care or treatment of the teeth or their supporting structures or gums, or dental procedures, Including but not limited to: extraction of teeth, restoration of teeth with or without fillings, crowns or other materials, bridges, cleaning of teeth, dental implants, dentures, periodontal or andodontic procedures, orthodontic treatment (e.g., braces), Immoral prosthetic devices, palatal expansion devices, bruxism appliances, and dental x-rays. This exclusion also applies to Phase 11 treatments (as defined by the American Dental Association) for TMJ dysfunction. This exclusion does not apply to an Accidental Dental Injury and the Child Cleft Lip and Cleft Palate Treatment Services category as described in the 'What Is Covered?" section. EM 1. Prescribed for uses other than the Food and Drug Administration (FDA) approved label indications. This exclusion does not apply to any drug that has been proven safe, effective and accepted for the treatment of the specific medical Condition for which the drug has been prescribed, as evidenced by the results of good quality controlled clinical studies published in at least two or more peer -reviewed full length articles in respected national professional medical journals. This exclusion also does not apply to any drug prescribed for the treatment of cancer that has been approved by the FDA for at least one indication, provided the drug is recognized for treatment of your particular cancer in a Standard Reference Compendium or recommended for treatment of your particular cancer in Medical Literature. Drugs prescribed for the 2. All drugs dispensed to, or purchased by, you from a pharmacy. This exclusion does not apply to drugs dispensed to you when: a. you are an inpatient in a Hospital, Ambulatory Surgical Center, Skilled Nursing Facility, Psychiatric Facility or a Hospice facility; b, you are in the outpatient department of a Hospital; c. dispensed to your Physician for administration to you in the Physician's office and prior coverage authorization has been obtained (if required); and d. you are receiving Home Health Care according to a plan of treatment and the Home Health Care Agency bills us for such drugs, including Self -Administered Prescription Drugs that are rendered In connection with a nursing visit. 3, Any non -Prescription medicines, remedies, vaccines, biological products (except insulin), pharmaceuticals or chemical compounds, vitamins, mineral supplements., fluodde products, over-the-counter drugs, products, or health foods, except as described in the Preventive Health Services category of the 'What Is Covered?" section. 4. Any drug which Is indicated or used for sexual dysfunction (e.g,, Cialis, Levitra, Viagra, Cayerject). The exception described in exclusion number one above does not apply to sexual dysfunction drugs excluded under this paragraph. Any Self -Administered Prescription Drug not indicated as covered in the 'What Is Covered?" section of this Benefit Booklet. 6. Blood or blood products used to treat hemophilia, except when provided to you for: What Is Not Owered? 3-2 a. emergency stabilization; b. during a covered Inpatient stay; or c. when proximately related to a surgical procedure. The exceptions to the exclusion for drugs purchased or dispensed by a pharmacy described in subparagraph number two do not apply to hemophilia drugs excluded under this subparagraph. * Drugs, which require prior coverage authorization when prior coverage authorization Is not obtained. * Specialty Drugs used to increase height or bone growth (e.g., growth hormone) except for Conditions of growth hormone deficiency documented with two abnormally low stimulation tests of less than 10 ng/ml and one abnormally low growth hormone dependent Paphos or for Conditions of growth hormone deficiency associated with loss of pituitary function due to trauma, surgery, tumors, radiation or disease, or for state mandated use as in patients with AIDS. Continuation of growth hormone therapy will not be covered except for Conditions associated with significant growth hormone deficiency when there is evidence of continued responsiveness to treatment. (See 'What is Covered?" section for additional information.) Experimental or Investigational Services, except as otherwise covered under the Bone Marrow Transplant provision of the Transplant Services category. except as covered in the Enteral Formulas subsection of the "What Is Covered?" section. Foot Care which is routine, Including any Health Care Service, in the absence of disease. This exclusion includes, but is not limited to: non- surgical treatment of bunions; flat feet, fallen arches; chronic foot strain; trimming of toenails corms, or calluses. General Exclusions include, but are not limited to: 1 any Health Care Service received prior to your Effective Date or after the date your coverage terminates; Z any Service to diagnose or treat any Condition resulting from or in connection with yourjob or employment; 1 any Health Care Services not within the service categories described in the 'What Is Covered?" section, any dust, or Endorsement attached hereto, unless such services are specifically required to be covered by applicable 4any Health Care Services provided by a Physician or other health care Provider related to you by blood or marriage; 5. any Health Care Service which is not Medically Necessary as determined by us or Monroe County BOCC and defined in this Booklet. The ordering of a Service by a health care Provider does not In itself make such Service Medically Necessary or a Covered Service; 6, any Health Care Services rendered at no charge; 7expenses for claims denied because we did not receive information requested from you regarding whether or not you have other coverage and the details of such coverage; 8. any Health Care Services to diagnose or treat a Condon which, directly or indirectly, resulted from or is in connection with: a) war or an act of war, whether declared or not; b) your participation in, or commission of, any act punishable by law as a misdemeanor or felony, or which constitutes hot, or rebellion; What Is Not Covemd? 3-3 c) your engaging in an illegal occupation; d) Services received at military or government facilities; or a) Services received to treat a Condition arising out of your service in the armed forces, reserves and/or National Guard; f) Services that are not patient -specific, as determined solely by us. 9. Health Care Services rendered because they were ordered by a court, unless such Services are Covered Services under this Benefit Booklet, and 10. any Health Care Services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group; or 11. Health Care Services that are not direct, hands-on, and patient specific, including, but not limited to the oversight of a medical laboratory to assure timeliness, reliability, and/or usefulness of test results, or the oversight of the calibration of laboratory machines, equipment, or laboratory technicians. Genetic screening, including the evaluation of genes to determine if you are a carrier of an abnormal gene that puts you at risk for a Condition, except as provided under the Preventive Health Services category of the 'What Is Covered?" section. Hearing Aids (external or implantable) and Services related to the fitting or provision of hearing aids, including tinnitus maskers, batteries, and cost of repair. Immunizations except those covered under the Preventive Health Services category of the 'What Is Covered?' section. Maternity Services rendered to a Covered Person who becomes pregnant as a Gestational Surrogate under the terms of, and in accordance with, a Gestational Surrogacy Contract or Arrangement. This exclusion applies to all expenses for prenatal, intra-partal, and post- partal Maternity/Obstetrical Care, and Health acting as a Gestational Surrogate. WWII Gestational Surrogacy Contract see the Definitions section of this Benefit Booklet. "What Is Covered?" section. vitamins, and food supplements, Oversight of a medical laboratory by a Physician or other health care Provider. "Oversight" as used in this exclusion shall, include, but Is jim Ilimited to, Ak-e oversI94-t 2. the calibration of laboratory machines or testing of laboratory equipment; 3. the preparation, review or updating of any protocol or procedure created or reviewed by a Physician or other health care Provide r in connection with the operation of the laboratory; and Necessary and not directly related to your treatment including, but not limited to: 1 . beauty and barber services; 1 clothing including support hose; 3. radio and television; 4guest meals and accommodations; 5. telephone charges', 6. take-home supplies; 7. travel expenses (other than Medically Necessary Ambulance Services); & moteVhotel accommodations; What to Not Covered? 3-4 9. air conditioners, furnaces, air filters, air or water purification systems, water softening systems. humidifiers, dehumidifiers, vacuun-, cleaners or any other similar equipment and devices used for environmental control or to 10. hot tubs, Jacuzzis, heated spas, pools, or memberships to health clubs; 11. heating -Ws,. hot water bafil n-ri-coe-vacks-'. 12. physical fitness equipment; 13. hand rails and grab bars; and 14. Massages except as covered In the "What Is Covered?"section of this Booklet. WWMMWMWZNMM���� Rehabilitative Therapies provided on an in the Hospital, Skilled Nursing Facility, Home Health Care, and Outpatient Cardiac, Occupational, Physical, Speech, Massage of the "What Is Covered?" section. Rehabilitative Therapies provided for the purpose of maintaining rather than improving your Condition are also excluded, and vasectormes. Sexual Reassignment, or Modcation cJudhg —1-Laujim�. �iy WmLlb Care Services related to such treatment, such 41,11mass"Um= NAME 031 limited to nicotine withdrawal programs and nicotine products (eg., gum, transdermal Iatches, affect performance primarily in sports -related activities-, all expenses related to physical Mj)lvm, - - - - bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. I Training and Educational Programs, or jx2teriQIs, laclu-II&S,aist lin.1taii to progmns or materials for pain management and vocational rehabilitation, except as provided or ordered by a Provider. Volunteer Services or Services which would normally be provided free of charge and any charges associated with Deductible, Coinsurance, or Copayment (if applicable) Provider. to lose, gain, or maintain weight, including without limitation: any weight contrailloss program; appetite suppressants; dietary regimens; food or food supplements; exercise a treatment plan for a Condition. What Is Not Covered? 3_5 of the requirements to be a Covered Service, by this Benefit Booklet. purposes of determining coverage, benefits, or �* 141 for the purpose of recommending or providing medical care. In conducting a review of Medical Nec5selty7BI.' VGF,Tray-mv�radRe-mad ice! f2cls review, however, Is strictly for the purpose of determining whether a Health Care Service provided or proposed meets the definition of Medical Necessity in this Booklet, In applying the definition of Medical Necessity in this Booklet to a specc Health Care Service, may be applied by BCBSF All decisions that require or pertain to independent professional medical/clinical judgement or training, or the need for medical services, are solely your responsibility and that of your treating Physicians and health care Providers. You and your Physicians are responsible for deciding what medical care should be rendered or received and when that care should be provided. Monroe County BOCC expenses incurred for medical care are covered under this Booklet. In making coverage decisions, neither BCBSF nor Monroe County BOCC will be deemed to participate in or override your decisions concerning your health or the medical decisions of your health care Providers. Examples of hospitalization and other Health include, but are not limited to, 1. staying in the Hospital because arrangements for discharge have not beer completed; 2. use of laboratory, x-ray, or other diagnostic testing that has no clear indication, or is not expected to alter your treatment: & staying in the Hospital because supervision.. in the home, or care in the home, is not available or inconvenient; or being hospitalized for any Service which could have been provided adequately in an alternate setting (e.g., Hospital outpatient department); or 4inpatient admissions to a Hospital, Skilled Nursing Facility, or any other facility for the purpose of Custodial Care, convalescent care, or any other Service primarily for the convenience of the patient or his or her family members or a Provider. Note. Whether or not a Health Care Service that a Provider may prescribe, recommend, approve, or furnish a Health Care Service does not mean that the Service Is Medically Necessary (as defined by this Benefit Booklet) or a Covered Service. Please refer to the "Definitions" section for the definitions of "Medically Necessary" or "Medical Necessity". Medical Necessity 41 L Wl Expenses This section explains what your share of the Benefits for the specific Covered Services which health care expenses will be for Covered are subject to a Copayment. Listed below is a Services you receive. In addition to the brief description of some of the Copayment information explained in this section, it is requirements that may apply to your plan. If the important that you refer to your Schedule of Allowed Amount or the Provider's actual charge Benefits to determine your share of the cost with for a Covered Service rendered is less than the by you and each of your Covered Dependents made by the Group Health Plan. Only those charges 'indicated on claims received for Covered Services will be credited toward the individual Deductible and only up to the applicable Allowed Amount. Please see your Schreguie of Benefits for more information. If your plan includes a family Deductible, after the family Deductible has been met by your family, neither you nor your Covered responsibility for the remainder of that Benefit Period, The maximum amount that any one Covered Person in your family can contribute towel til, mulig Deductibl Please see your Schedule of Benefits for more information. ■ ........... . . . . . ..... to a Copayment requirement. This is the dollar anfroint yaw have 4 pay when yo;v recapae those Services. Please refer to your Schedule of the Allowed Amount or the Provider's actual charge for the Covered Service. If your plan is a Copayment plan, the 11urable Medical E quipment, Medical -"harmacy, Prosthetics, and Orthotes. that Is subject to a Cippayment Is rendered during the same office visit, you will be responsible for a single Copayment which will not exceed the highest Copayment particular Health Care Services rendered. 2. Inpatient Facility Copayment: The inpatient facility Copayment must be satisfied by you, for each inpatient admission to a Hosm al Fadfitv- or Substance Abuse Facility, before any payment will be made for any claim for inpatient Covered Services. The inpatient inpatient admissions to a Hospital, Psychiatric Facility or Substance Abuse Understand ra Your Share of Hearn Cam Expenses 5-1 Facility in or outside the state of Florida. Additionally, you will be responsible for out- of-pocket expenses for Covered Services provided by Physicians and other health care professionals for inpatient admissions. Note. Inpatient facility opayments may vary depending on the facility chosen, Please see the Schedule of Benefits for more information). 3. Outpatient Facility opayment. The outpatient facility Copsyment must be satisfied by you, for each outpatient visit to a Hospital, Ambulatory Surgical Center, Independent Diagnostic Testing Facility, Psychiatric Facility or Substance Abuse Facility, before any payment will be made for any claim for outpatient Covered Services, The Outpatient Facility opayment applies regardless of the reason for the visit, and applies to all outpatient visits to a Hospital, Psychiatric Facility or Substance Abuse Facility in or outside the state of Florida. Additionally, you will be responsible for out- of-pocket expenses for Covered Services provided by Physician and other healthcare professionals. Note. Outpatient facility Copayments may vary depending on the facility chosen. (Please see the Schedule of Benefits for more information). 4. Emergency Room Facility opayment: The emergency room facility opayment applies regardless of the reason for the visit, is in addition to the applicable Coinsurance amount, and applies to emergency room facility Services in or outside the state of Florida, The emergency mom facility Copayment must be satisfied by you for each visit. If you are admitted to the Hospital as an inpatient at the time of the emergency room visit, the emergency roam facility opayment will be waived, but you will still be responsible for the inpatient facility apayment. any payment will be made for any claim for inpatient Health Care Services. The Hospital m - I Deductible requirement, and applies to all Hospital admissions in or outside the state of Florida. Deductible The Emergency Room Per Visit Deductible (PVD) Is set forth In the Schedule of Benefits. The Emergency Room Per Visit Deductible applies regardless of the reason for the visit, is in addition to the Deductible, and applies to of Florida. The Emergency Room Per Visit Deductible must be satisfied by each Covered Plan Participant for each visit If the Covered Plan Patticipant Is aimittai 4. tha H*sXital at t time of ft emergency room visit, the Emergency Room Per Visit Deductible will be waived. I must be satisfied before any portion of the Allowed Amount will be paid for Covered Services. For Services that are subject to Caixsumxce, tke Colitsir-auxce petnex1tangs of t! applicable Allowed Amount you are responsitil for is listed in the Schedule of Banat I wwiffmmlyj� m-l-Mgmr-7m, a-MTN= Once you have reached the individual out-of- "4wmiiw�' �-- lil"- of Benefits, you will have no additional out-of- pocket responsibility for the remainder of that Benefit Period and we will pay 100 percent of Understanding Your Share of Health Care Fxroeules 5.2 the Allowed Amount for Covered Services rendered during the remainder of that Benefit Period. Family out-of-pocket maximum If your plan Includes a family out-of-pocket maximum, once your family has reached the family out-of-pocket maximum amount listed in the Schedule of Benefits, neither you nor your covered family members will have any additional out-of-pocket responsibility for the remainder of that Benefit Period and we will pay 100 percent of the Allowed Amount for Covered Services rendered during the remainder of that Benefit Period. The maximum amount any one Covered Person in your family can contribute toward the family out-of-pocket maximum, if applicable, is the amount applied toward the individual out-of- pocket maximum, Please see your Schedule of Benefits for more Information. Note: Any applicable Copayments and Coinsurance amounts will accumulate toward the out-of-pocket maximums. Any benefit penalty reductions, Deductible, PAD, PAD, non - covered charges or any charges in excess of the Allowed Amount will not accumulate toward the out-of-pocket maximums. If the Group has purchased Prescription Drug coverage, any applicable Cost Share under the Prescription Drug coverage, will not apply to the Deductible or the out-of-pocket maximums under this Booklet. WMERIMEEMEM You will be given credit for the satisfaction or partial satisfaction of any Deductible and Coinsurance maximums met by you under a prior group insurance, blanket insurance, or franchise Insurance or group Health Maintenance Organization (HMO) policy or plan maintained by Monroe County BOCC if the coverage provided hereunder replaces such a policy or plan. This provision only applies If the prior group insurance, blanket insurance, franchise insurance, HMO or plan coverage was in effect immediately preceding the Effective &QW44"s Booklet. This provision Is only applicable for you during the initial Benefit Period of coverage under this Benefit Booklet and the following rules apply: R.S. For the Initial Benefit Period of coverage under this Benefit Booklet only, charges credited towards your Deductible - I aMyirefrr prior AdicTvi�-Xlerh for Services rendered during the 90-day Date of the coverage under this Benefit requirement under this Booklet. Charges credited by Monroe County BOCC's prior policy or plan, towards your Coinsurance Maximum, for Services rendered during the 90-day period came-mg,,_,under this Beo.#A;t BoankLaL,2itAl b-_ -credited to your out-of-pocII ket maximum ut,der Vllkils Booklet. 3. Prior coverage credit towards the Deductible or out-of-pocket maximums will only be given for Health Care Services which would have been Covered Services under this Booklet. ...... .... Group. You and/or Monroe County BOCC are responsible for providing BGSSF with any information necessary for BCBSF to apply this prior coverage credit. Understanding Your Sham of Health Care Expenses 53 amounts applied to your benefit maximums under the prior group plan, will be applied toward your benefit under this Booklet. In addition to your share of the expenses described above, you are also responsible for: 1. any applicable opayments; 2. expenses incurred for non -covered Services; 3. charges in excess of any maximum benefit limitation listed in the Schedule of Benefits (e.g., the Benefit Period maximums); 4. charges in excess of the Allowed Amount for Covered Services rendered by Providers who have not agreed to accept the Allowed Amount as payment in full; 5. any benefit reductions; 6. payment of expenses for claims denied because we did not receive information requested from you regarding whether or n you have other coverage and the details of such coverage; and I 7. charges for Health Care Services which are excluded. Additionally, you are responsible for any contribution amount required by Monroe County BOCC, How Benefit Maximums Will Be Credited Only amounts actually paid for Covered Services v4 �*cregfite�, taM3 grey apislicable benefit maximums. The amounts paid which are credited towards your benefit maximums will be based an the Allowed Amount for the Covered Services provided. Understanding Your Share of Health Care Expenses l: IRT., Rmlf M.- 13M It is important for you to understand how the Z111.4d, you are responsible for paying under this Booklet. This section, along with the Schedule of Benefits, describes the health care Provider options available to you and the payment rules for Services you receive. expenses" or "out-of-pocket' refers to the A Coinsurance amounts for Covered Services. You are entitled to preferred provider type benefits when you receive Covered Services from In -Network Providers. You are entitled to ni i M_ service when you receive Covered Services from Traditional Program Providers or BlueCard conformity with Section 7: BlueCard (Out -of - State) Program. With BlueOptions, you may choose to receive Services from any Provider. However, you may Network Provider. Although you have the option to select any Provider you choose, you are with an In -Network Family Physician. There are several advantages to selecting a Family Physician. Family Physicians are trained to provide a broad range of medical care and can be a valuable resource to coordinate your overall healthcare needs. Developing and mom= allows the physician to become knowledgeable about you and your family's health history. A you need to visit a specialist and also help you find one based an their knowledge of you and your specific healthcare needs. Types of Family Physicians are Family Practitioners, General Practitioners, Internal Medicine doctors and Pediatricians. Addonally, care rendered by pocket expenses for you. Whether you select a that using In-Networly Providers may result in lower out-of-pocket expenses for you. You should always determine whether a Provider is In -Network or Clut-of-pletwork prior to receiving Services to determine the amount you are responsible for paying out-of-pocket. In addon to the participation status of the Provider, the location or setting where you receive Services can affect the amount on V%7WfflRN I paying out-of-pocket will vary whether you receive Services in a Hospital, a Provider's office, or an Ambulatory Surgical Center. Please refer to your Schedule of Benefits for expenses for such situations. After you and your Physician have determined the plan of treatment most appropriate for your care, you should refer to the 'What Is Covered?" section and your Schedule of Benefits to find out if the specific Health Care Services are covered and how much you will have to pay. You should al consult with your Physician to determine the most appropriate setting based on your health care and financial needs. Physicians, Hospitals and Other Provider cranny 6-1 . . . . . . . . . . . . ....... ..... Network. 1 . If in Florida, review your current BlueOptione Provider Directory; 2. If in Florida, access the BlueOptions Provider directory at BCBSF's web -site at www.flohdablue.com; and/or 3. If outside of Florida, access the on-line Blue and Doctor and Hospital Finder at www,floddablue.com; and/or 4. Call the customer service phone number In this Booklet or on your Identification Card to search for PP O providers. Please remember that changes to Provider network participation can occur at any time. Consequently, it is your responsibility to determine whether a specific Provider Is In - Network at the time you receive Covered Services. In -Network Providers When you use In -Network Providers, your out- of-pocket expenses for Covered Services may be lower. Payment will be based on the Allowed Amount and your share of the cost will be at the In -Network benefit level listed in the Schedule of Benefits. Clut-of-Ildletwork Providers When you use Out -of -Network Providers your out-of-pocket expenses for Covered Services will be higher. We will base our payment on the lhowl�n the arhw:luW_aL8enefltsFljdkerj t*_P Out-of-Idetwork Provider is a Traditional Program Provider or a BlueCard (Out -of -State) Traditional Program Provider, our payment to such Provider may be under the terms of that Provider's contract. If your Schedule of Benefits and BlueOptions Provider directory do not include a Provider as In -Network under your Physicians, Hosocki and Other Provider Ow G-2 In -Network Out -of -Network expenses Any applicable Copayments, Deductible(s) and/or Coinsurance requirements'. 7 are you 49 are Expenses for Services which are not covered', responsible for Expenses for Services in excess of any benefit maximum limitations", paying? a Expenses for claims denied because we did not receive information requested from you regarding whether or not you have other coverage and the details of such coverage; and 0 Expenses for Services which are excluded. Who Is V The Provider will file the claim �Participant. 0 You are responsible for filing the responsible for for you and payment will be claim and payment Will be made filing your made directly to the Provider. 1 ct �y to 1 directly to the Covered Plan claims? Participant. If you receive Services 'I from a Provider who participates in our Traditional Program or is a BlueCard (Out -of -State) Traditional Program Provider, the Provider will file the claim for you. In those instances payment will be made directly to the Provider. Can you be billed NO. You are protected from YES. You are responsible for paying the difference being billed for the difference in the difference between what we pay between what the the Allowed Amount and the and the Providers charge. However, Provider Is paid Provider's charge when you use if you receive Services from a and the Provider's In -Network Providers. The Provider who participates in our charge? Provider will accept the Allowed Traditional Program, the Provider will Amount as payment In full for accept our Allowed Amount as Covered Services except as payment In full for Covered Services otherwise permitted under the since such Traditional Program terms of the Provider's contract Providers have agreed not to bill you and this Booklet. for the difference. Further, under the Blue and (Out -of -State) Program, when you receive Covered Services from a BlueCard (Out -of -State) Traditional Program Provider, you may be responsible for paying the difference between what the Host Blue pays and the Provider's billed charge. Note. You are solely responsible for selecting a Provider when obtaining Mealth Care Services and for verifying whether that Provider is In -Network or Out -of -Network. You are also responsible de the corresponding payment options, if any, at the time the Health Care Services are rendered. Physicians, Hospitals and Other Provider Options 6-3 When you receive Covered Services from a Physician you will be responsible for a Copayment and/or the Deductible and the applicable Coinsurance. Several factors will your Schedule of Benefits, whether the Physician is In -Network or Out-of-Oletwork, the �,_&MIACA36 and the Physician's specialty. Remember that the location or setting where a Service is rendered can affect the amount you are responsible for paying out-of-pocket. After you and your Physician have determined the consult with your Physician to determine the most appropriate setting based on your health care and financial needs. the applicable Copayments, Coinsurance percentage and/or Deductible amount you are responsible for paying for Physician Service& Each time you receive inpatient or outpatient Covered Services at a Hospital, in addition to any out-of-pocket expenses related to Physician Services, you will be responsible for out-of- pocket expenses related to Hospital Services. In -Network Hospitals have been divided into two groups that are referred to as "options" on the Schedule of Benefits. The amount you are responsible for paying out-of-pocket is different for each of these options. Remember that there are also different out-of-pocket expenses for Out-of-pletwork Hospitals. Hospital, it is important when choosing a Physician that you determine the Hospitals admits to by contacting the Physician's office. This will provide you with Information that will pocket costs may be in the event you are hospitalized. Certain medications, such as injectable, oral, inhaled and infused therapies used to treat complex medical Conditions are typically more difficult to maintain, administer and monitor when compared to traditional Drugs. Specialty Drugs may require frequent dosage adjustments, special storage and handling and or routinely stocked by Physicians' offices, mostly due to the high cost and complex handling they require. Using the Specialty Pharmacy to provide these Specialty Drugs should lower the amount you 11i)a4-k1dV4"&1Z&_ to preserve your benefits. that specialize in a specific Service(s). While they may not be included as In -Network Providers for your plan. Additionally, all of the Services that are within the scope of certain Providers' licenses may not be Covered Services under this Booklet. Please refer to the V -F 41 No Physicians, Hospitals and Other Provider Options &_4 these Providers. You may be able to receive certain outpatient Services at a location other than a Hospital. The amount you are responsible for paying for Services rendered at some alternative facilities Is generally less than if you had received those same Services at a HospitaL Remember that the location of service can impact the amount you are responsible for paying out-of-pocket. After you and your Physician have determined the plan of treatment most appropriate for your care, you should refer to the Schedule of Benefits and consult with your Physician to determine the most appropriate setting rased an your health care and financial needs. When Services are rendered at an outpatient facility other than a Hospital there may be an out-of-pocket expense for the facility Provider as well as an out-of- pocket expense for other types of Providers. Except as set forth in the last paragraph of this section, any of the following assignments, or attempted assignments, by you to any Provider will not be honored: an assignment of the benefits due to you for Covered Services under this Benefit im an assignment of your right to receive payments for Covered Services under this Benefit Booklet; or an assignment of a claim for damage resulting from a breach, or an alleged breach of the terms of this Benefit Booklet. We specifically reserve the right to honor an assignment of benefits or payment by you to a Provider who: 1 ) is I n-Network under your plan of coverage; 2) Is a .. Provider even coverage; 3) is a Traditional Program Provider; and P.Program Provider; 5) is a r Traditional Program Provider; 6) Is a licensed Hospital, Physician, or dentist and the benefits . :: -- ;F,,.. Ambulance Provider transportation for Services from the location where an "emergency medical condition", defined first occurred to a Hospital, and the benefits to care provided Florida Statutes. A written attestation of the assignment benefits a be required. Physic rn% Mospitats and Other ProviderOptions 6-5 Whenever you obtain Health Care Services ox-tside of o*r servica area, the claims hw these Services may be processed through one of these Inter -Plan Programs, which include the pzwz�_41 National Account arrangements available belween us and other Blue Cross and Blue care Providers that have a contractual agreement (i.e., are "participating providers") with the local Blue Cross and/or Blue Shield Licensee In that other geographic area ("Host from non -participating health care Providers. Our payment practices in both Instances are described below. Under the BlueCard Program, when you area served by a Host Blue, we will remain responsible for fulfilling our contractual obligations, However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating health care Providers. Whenever you access Covered Services outside our service area and the claim is processed tkr*ugk IWQ BlueC24 Progr2st, flie amount you pay for Covered Services is calculated based on the lower of: Covered Services', or 3�M INJIMMMM5101-TIRM Often, this "negotiated price" will be a simple Blue pays to your health care Provider. litto account special arrangements with your health care Provider or Provider group that may include types of settlements, Incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of health care Providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of trasnachriv. usAficafloaq natwi ek-sve- Wowever. for your claim because they will not be applied retroactively to claims already paid, If any state laws mandate other liability calculation methods, including a surcharge, we k*% Services according to applicable law. Service Area ProvidIII ers, the paymIII a ent will be based on the Allowed Amount as defined in the Benefit Booklet. Eilmward mut-d-Stalin Program 1-1 WE 136�1 ' M117119NIRM BCBSF has established (and from time to time establishes) various customer -focused health education and information programs as well as benefit utilization management and utilization review programs. Under the terms of the ASO Agreement between BCSSF and Monroe County BOCC, SCSSF has agreed to make these programs available to you. These programs, collectively called the Blueprint for h-PLi;_krams.-are-dezl,gned to I *-*'irovicle yQu with information that will help you make more Informed decisions about your health, 2) help facilitate the management and review of coverage and benefits provided under this Booklet and 3) present opportunities, as explained below, to mutually agree upon alternative benefits or payment alternatives for Services. Some BluePrint For Health Programs may not be available outside the state of Florida. The admission notification requirements vary depending on whether you are admitted to a Hospital, Psychiatric Facility, Substance Abuss Facility or Skilled Nursing Facility which is In - Network or Out -of -Network. tLe_,2e1ectms,, planned, urgent or emergency) to In -Network Hospital% Psychiatric Facilities, Substance Abuse Facilities or Skilled Nursing Facilities. While it is the sole responsibility of the In -Network Provider located in Florida to comply with our admission notification requirements, you should ask the Hospital, ■ SIC ric F�Mny, Skilled Nursing Facility (as applicable) if we have been notified of your admission, For an admission outside of Florida, you or the Hospital, Psychiatric Facility, Substance Abuse should notify us of the admission. Making sure for Health Programs available to you. You or the Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility (as applicable) may notify us of your admission by calling the toll free customer service number on your I D card. For admissions to an Out-of-pletwork Hospital, ftychiahic Facility, SwAstanca Abwsa Facility -#r Skilled Nursing Facility, you or the Hospital, r-sychiatac Facility, Swkstance A*wsa Facility *r Skilled Nursing Facility should notify BCBSF of the admission. Notifying BCSSF of your admission will enable BCBSF to provide you information about the Blueprint for Health Programs available to you. You or the Hospital may notify BCSSF of your admission by calling card. Jr-WIT-110t Under the inpatient facility program, we may review Hospital stays, Hospice, Inpatient rendered during the course of an inpatient stay or treatment program. We may conduct this review while you are inpatient, after your discharge, or as part of a review of an episode Musixint for Health Programs B-1 of inpatient care to another for ongoing treatment. The review is conducted solely to determine whether we should provide coverage and/or payment for a particular admission or Health Care Services rendered during that admission. Using our established criteria then in effect, a concurrent review of the inpatient stay may occur at regular intervals, including in advance of a transfer from one inpatient facility to another. We will provide notification to your Physician when inpatient coverage criteria are no longer met. In administering the inpatient facility program, we may review specific medical facts or information and assess, among other things, the appropriateness of the Services being rendered, health care setting and/or the level of care of an inpatient admission or other health care treatment program. Any such reviews by us, and any reviews or assessments of specific medical facts or information which we conduct, are solely for purposes of making coverage or payment decisions under this Benefit Booklet and not for the purpose of recommending or providing medical care, OWN Management Program Certain NetworkBlue Providers have agreed to participate in our focused utilization management program. This pre -service review program is intended to promote the efficient delivery of medically appropriate Health Care Services by NetworkBlue Providers, Under this program we may perform focused prospective reviews of all or specific Health Care Services proposed for you. In order to perform the review, we may require the Provider to submit to us specific medical information relating to Health Care Services proposed for you. These Network8lue Providers have agreed not to bill, or collect, any payment whatsoever from you or us, or any other person or entity, with respect to a specific Health Care Service if., 1. they fail to submit the Health Care Service for a focused prospective review when U1011 dalOWIMAR with us; or 2. we perform a focused review under the focused utilization management program and we determine that a Health Care Service Is not Medically Necessary in accordance with our Medical Necessity criteria or inconsistent with our benefit guidelines then in effect unless the following exception applies. Certain NalwarkSlue Physicians licensed as Doctors of Medicine (M.D.) or Doctors of :1 14"Qxjl"� determined to be not Medically Necessary by BCBSF under this focused utilization 9 vou receive the a. they give you a written estimate of your financial obligation for the Service; a. you agree to assume financial responsibility for such Service. It is important for you to understand our prior and receive affects these requirements and go ultimately how much you are responsible for Seit paying under this Bnefit Booklet. prior coverage authorization from us for: 1. advanced diagnostic imaging Service such as CT scans, MRIs, MRA and nucle Imaging; I Blueprint for Health Programs &2 2. Autism Spectrum Disorder; Mental Health; and Substance Dependency Services; and 3. other Health Care Services that are or may become subject to a prior coverage authorization program or a pre -service nolffication program as defined and W-1731MEMMI I Mytheal "IRWRIM-1 . . . . . . . . . . . . an I n-Network Provider or an Out -of -Network to comply with our prior coverage authorization requirements, and therefore you will not be responsible for any benefit reductions If prior coverage authorization is not obtained before Medically Necessary Services are rendered. Once we have received the necessary medical the Inforrnation and make a prior coverage criteria then in effect. The Provider will be notified of the prior coverage authorization decision. WffffMV1ZWMZ=r 1 . In the case of advanced diagnostic imaging Services such as CT scanSr I'VIRIs, MIRA and nuclear imaging, It is your sole responsibility to comply with our prior coverage authorization requirements when rendered or referred by an Out-of-pletwork Provider before the advanced diagnostic imaging Services are provided, Your failure to obtain prior coverage authorization will result in denial of . . . . . . . . . . . . . . . . ..... ram coverage authoNI rization for advanced customer service phone number on the back of your 10 Card. 2. In the case of Autism Spectrum Disorder, Mental Health, and Substance Dependency Services under a prior coverage authorization or pre -service notification program, it is your sole responsibility to comply with our prior coverage authorization or pre -service notification requirements when rendered or referred by an Out -of -Network Provider, before the Services are provided. Failure to obtain prior coverage authorization will result in denial of coverage for such Services. 3. In the case of other 6ealth Care Services under a prior coverage authorization or pre - service notification program, it is your sole responsibility to comply with our prior coverage authorization or pre -service notification requirements when rendered or referred by an Out -of -Network Provider, before the Services are provided. Failure to obtain prior coverage authorization or provide pre -service notification may result in denial of the claim or application of a financial penalty assessed at the time the claim is presented for payment to us. The penalty applied will be the lesser of $500 or 20% of the total Allowed Amount of the claim. The decision to apply a penalty or deny the claim will be made uniformly and will be Identified in the notice describing the prior coverage authorization and pre -service notification programs. iW Ww been received from you and/or the Out -of - Network Provider, BCBSF or a designated vendor, will review the information and make a VAV6-*x0Znr our established criteria then in effect. You will be noffied of the prior coverage authorization decision. Blueprint for Herr m Programs !3-3 BCBSF will provide you information for any Out - of -Network Health Care Service subject to a prior coverage authorization or pre -service notification program, including how you can obtain prior coverage authorization and/or provide the pre -service notification for such Service not already listed here. This information will be provided to you upon enrollment, or at least 30 days prior to such Out -of -Network Services becoming subject to a prior coverage authorization or pre -service notification program. See the 'Claims Processing" section for authorcartion is denied. Note: Peter coverage authertzation Is not 0441 for the treatment of an Emergency Medical Condition. WOOL11 r-lueseuRT—Ty 1- - voluntary programs for certain members. These programs may address health promotion, prevention and early detection of disease, chronic illness management programs, case management programs and other member focused programs. Personal Case Management Program The personal case management program focuses an members who suffer from a catastrophic illness or injury. In the event you have a catastrophic or chronic Condition, we may, in BCBSFs sole discretion, assign a Personal Case Manager to you to help coordinate coverage, benefits, or payment for Health Care Services you receive. Your oertici�fetion in thin oro�rarrt Is corn lately voluntary. Under the personal case management program, you may be offered alternative benefits or payment for cost-effective Health Care Services. These alternative benefits or payments may be you meet BCBSFs case management criteria then in effect. Such alternative benefits or payments, if any, will be made avaiiable in accordance with a treatment plan with which agree to In writing. In addition, Monroe County BOCC will be required to specifically agree to kZd Z M-MMUMNOW the personal case management program have way obligates BCBSF, Monroe County BOCC, or pay a same OF 51mildl 'ated v4uab1"VMM= contained in this section shall be deemed a waiver of Monroe County BOCC's right to terms. The terms of this Booklet will continue to apply, except as specifically modified in writing in accordance with the personal case management program rules then in effect. and Illness Management Programs These Blueprint for Health Programs may include health information that supports health care education and choices for healthcare issues. These programs focus on keeping you well, help to identify early preventive measures of treatment and help covered individuals with chronic problems to enjoy lives that are as productive and healthy as possible. These programs may include prenatal educational Conditions such as diabetes, cancer and heart disease. These programs are voluntary and are designed to enhance your ability to make health care needs. You may call the toll free customer service number on your IS card for more information. Your parlicigation in this program..1s.cOmIgletely voluntaU. Blueprint for Health Programs B-A BCGSF'S BLUEPRINT FOR HEALTH PROGRAMS All decisions that require or pertain to independent professional medicallclinical judgment or training, or the need for medical services, are solely your responsibility and the responsibility of your Physicians and other health care Providers. You and your Physicians are responsible for deciding what medical care should be rendered or received, and when and how that care should be provided. Monroe County BOCC is ultimately responsible for determining whether expenses, which have *.-er Y-01 1Po(incw*wLWo*Tx6#d cm - will be, covered under this Booklet. In fulfilling this responsibility, neither BCBSF nor Monroe CoviAty RQCC Willit-vieened ta pakicipate in *P override the medical decisions of your health care Provider. Please note that the Hospital admission Health Program may be discontinued or modified at any time without notice to you or your consent. Sluepdnt for Health Pmgrams 0-5 [119MORM Generally, there is no coverage under this Booklet for Health Care Services to treat a Pre-existing Condition, or Conditions arisin frar%.2 P "-eWQMwg -on havi been continuously covered under this Booklet for a 12-month period. This 12- month Pre-existing Condition exclusionary perind begins on the first day of the Waltin Period if you are an initial enrollee; or your Eft,dive Date-ff�- &aW uFrftf-the Bwok III if you are a special or annual enrollee. Th exclusionary period also applies to any prescription drug that is prescribed In connection with a Pre-existing Condition. period does not apply to: I . the Covered Plan Participant and each Covered Dependent who was covered under the Group's prior medical plan on the date immediately preceding the Effective Date of coverage under this Booklet; 2. you if you were enrolled during the Initial Enrollment Period prior to the Effective MUMM 3. you when the Group has elected to waive, in writing, at the time of Group Application the Pre-existing Conditions exclusionary period for all subsequent Eligible Employees and/or Eligible Dependents; 4. any Condition for a Covered Person who is under the age of 19 as of the effective date of this Benefit Booklet, or if enrolled thereafter, is under the age of 19 at the M�il=illl MERIM 6. Genetic Information In the absence of a diagnosis of the Condition; 7. routine follow-up care of breast cancer after the person was determined to be free of breast cancer; 8. Conditions arising from domestic violence; or " I 'nhe *too diseases of amino acid, organic ac4 6. In carbohydrate or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Genetic Information, as used above, means information about genes, gene products, and inherited characteristics that may derive from the individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories, and direct analysis of genes or chromosomes. A Pre-existing Condition means any Condition related to a physical or mental Condition, regardless of the cause of the Condition, for which medical advice, diagnosis, care, or treatment was recommended or received during the six-month period immediately preceding* 1, the first day of your Waiting Period for initial enrollees; or 2. your Effective Date of coverage under the Group Health Plan for special and annual enrollees. Exclusionary Period No matter whether you enroll when first eligible or at a later date (such as an Annual Open Enrollment Period or as a result of Special Enrollment), you Pre-esuning Condilons Exclusion Period 9-- may be able to reduce or even eliminate the Pre-existing Conditions exclusionary period if you have prior Creditable Coverage. If you are enrolling when you are first eligible for coverage and you have no more than a 63 day break in Creditable Coverage as of your Enrollment Date under this Booklet, your Pre-existing Conditions exclusionary period will be reduced by the amount of poor Creditable Coverage you have. this Booklet at any other time as allowed under its terms, such as during an Annual Open Enrollment Period or a Special Enrollment Period, your Pre-existing Conditions exclusionary period will be reduced by the amount of any Creditable Coverage you have; provided there is no If you have no Creditable Coverage or none that can reduce the Pre-existing Conditions exclusionary period, the full 12-menth Pre- existing Conditions exclusionary period will apply. Creditable Coverage is health care coverage that may include any of the following: 1. a group health insurance plan; 1 Individual health insurance; 1 Medicare Part A and Part B; 4, Medicaid; 5. benefits to members and certain former members of the uniformed services and their dependents; 6, a medical care program of the Indian Health Service or of a tribal organization; 7. a State health benefits risk pool; 8. a health plan offered under chapter 89 of Title 5, United States Code; 9. a public health plan; 10. a health benefit plan of the Peace Corps', 11. State Children's Health Insurance Program (CHIP); 12. public health plans established by the federal government; or 13. public health plans established by foreign governments. W7MMUKHM.-mm; 1: You may provide a Prior/Concurrent Coverage Affidavit or Certification of Creditable Coverage to TTA W� QevI I owl 0 1 UITW[�aTM77-7 group health plans are required to provide a certification of Creditable Coverage to you upon 4 request up to 24 months after tenrlination of your prior health coverage. if you do not provide a certification, then you must provide some other 41, "121� an I D card or health insurance bill from a prior carrier and attest to the amount of time you were covered under the Creditable Coverage, Pre-emisfing CondilJons Exclusion Period �2 to participate in the Monroe County Group Health Plan, and who meets and continues to moak4z."S Booklet, shall be entitled to apply for coverage under this Booklet, These eligibility requirements are binding upon you and/or your eligible family members. No changes in the eligibility requirements will be permitted except as permitted by Monroe County BOCC. Acceptable documentation may be required as proof that an individual meets and continues to meet the eligibility requirements such as a court ....... . . . . . . . . . ........... described in the "Enrollment and Effective Date eq-t...--iremen Plan Participants 1111713009M= Plan Participant, an Individual must be an Eligible Employee or Eligible Retiree. An Eligible Employee must meet each of the following requirements: 1. The employee must be a bona fide employee of a Monroe County Employ participating in the Monroe County Grol Health Plan; I 2. The employee must be actively working 25 hours or more per week on a regular basis; 3. The employee must have completed the applicable Waiting Period of 60 days of continuous service; and 4. The employee must meet any additional eligibility requirement(s) required by Monroe County BOCC. Note: Employees and qualified Dependents are eligible for coverage on the day following Val saw uly us can Waiting Period. Monroe County BOCC's coverage eligibility classifications may be expanded to include: 1. retired employees; 2. Constitutional Officers or their Employees; 3. additional job classifications; ,ik employees of affiliated or subsidiary companies of Monroe County BOCC; and 5. other Individuals as detennined by Monroe County BOO. Monroe County BOCC shall have sole discretion concerning the expansion of eligibility classifications. ..... ..... An individual who meets the eligibility criteria 1 The Covered Plan Participant's spouse under a legally valid existing marriage under Federal Law. 2. The Covered Plan Participant's natural, newbom, adopted, Foster, or step childfren) (or a child for whom the Covered Plan Participant has been court -appointed as legal guardian or legal custodian) who has not reached the end of the Calendar Year in which he or she reaches age 26 (or in the case of a Foster Child, is no longer eligible under the Foster Child Program), regardless of the dependent child's student or marital status, financial dependency an the Covered Plan Participant, whether the dependent child resides with the Covered Plan Participant, or whether the dependent child Eligibility For Coverage 1C-1 is eligible for or enrolled in any other group health plan. 3. The newborn child of a Covered Dependent child who has not reached the end of the Calendar Year in which he or she becomes 26. Coverage for such newborn child will automatically terminate 18 months after the birth of the newbom child, Note; If a Covered Dependent child who has reached the and of the Calendar Year in which he or she becomes 26 obtains a dependent of their own (e.g., through birth or adoption) such newborn child will not be eligible for this coverage and the Covered Dependent child will also lose his or her eligibility for this coverage. It Is the Covered Plan Participant's sole responsibility to establish that a child meets the applicable requirements for eligibility. This eligibility shall terminate on the last day of the Calendar Year in which the dependent child reaches age 26. Extension of Eligibility for Dependent Children A Covered Dependent child may continue coverage beyond the end of the Calendar Year In which he or she reaches age 26, provided he or she is: 1. unmarried and does not have a dependent, Z a Florida resident or a full-time or part-time student; 3. not enrolled in any other health coverage policy or group health plan; and 4. not entitled to benefits under Title XVIII of the Social Security Act unless the child is a handicapped dependent child. This eligibility shall terminate on the last day of the Calendar Year in which the dependent child reaches age 30. In= & rbexerniAn ".x4fe-r-t key&xl - V 266,V the child is: I . otherwise eligible for coverage under the - Group Health Plan; 2. Incapable of self-sustaining employment bry reason of mental retardation or physical handicap; and 3. chiefly dependent upon the Covered Plan Participant for support and maintenance provided that the symptoms or causes of the child's handicap existed prior to the child's 26th birthday. the month In which the dependent child no longer meets the requirements for extended eligibility as a handicapped child. Absence from School IL M allu 16-71 lu 1777M-Arntrw part-time student at an accredited post- secondary institution, who takes a physician certified medically necessary leave of absence YAI still is-sty(i r eligibility purposes under this Booklet for the earlier of 12 months from the first day of the leave of absence or the date the Covered for coverage under this Booklet. 511gibility ForCoverage 10-2 [BMW= NSA Eligible Employees, Eligible Retirees and according to the provisions below. W11 Ell ■ will not be covered under this Benefit Booklet. Neither BCBSF nor Monroe County BOCC will I 1.112 who is not property enrolled. Any Employee, Eligible Retiree, or Eligible Dependent who is eligible for coverage under the provisions set forth below. Employee or Eligible Retiree must: 1, complete and submit, through Monroe County BODO. Benefits Office, the Enrollment Form; 2. provide any additional Information needed to determine eligibility, at the request of BOSSE or Monroe County BOCC Benefits Office; 4. complete and submit, through Monroe County BOCC Benefits Office, an Enrollment Form to add Eligible Dependents. ■ must elect one of the types of coverage available under Monroe County BOCC's program. Such types may include: coverage provides coverage for the Employee/Retiree only. coverage provides coverage for the under a legally valid existing marriage under Federal Law or Domestic Partner. coverage provides coverage for the Employee/Retiree and the covered child(ren) only. Employee/Family Coverage - This type of coverage provides coverage for the &Vwlticn I . I AWNW5PW for each Covered Dependent based on the during which an Eligible Employee or Eligible Degey,degrt is fifst eble to exroll, I A. .. . ... .. ... .. days later. i FRAW of time during which each Eligible Employee or coverage from among the alternatives included in Monroe County BOCC's health benefit program. The period is established by Monroe County BOCC, occurs annually, and will take of time (unless otherwise noted) immediately foU.-WhIPS a spxd,21 circumistaince4uriKg vfKk�A a;k Eligible Employee or Eligible Dependent may apply for coverage. Special circumstances are described in the Special Enrollment Period an section. Enrollment and Effective Date of Carverage 11-1 Employee Enrollment and may only enroll under this Benefit Booklet duidnWhe Special Enrollment Period. The Effective Date will be the date specified by Monroe County BOCC. An individual may be added upon becoming an Eligible Dependent of a Covered Plan Participant. Below are special rules for certain Eligible Dependents. N. is an Eligible Dependent, the Covered Plan Participant must submit an Enrollment Form to Office during the 30-day period immediately following the date of birth. The Effective Date of If timely notice is given, no additional contribution will be charged for coverage of the newborn child for not less than 30 days after the birth of the child. If timely notice is not received, the applicable contribution will be charged from the date of birth. The applicable contribution for the child will be charged after the initial 30-day period in either case. Coverage will not be denied for a newborn child if the Covered Plan Participant provides notice to Monroe County BOCC Benefits Office and an Enrollment Form is received within the 60-day period of the birth of the child and any applicable contribution is paid back to the date of birth. the date of birth, the newborn child will not be covered, and may only be enrolled under this Benefit Booklet during an Annual Open Enrollment Period, or in the case of a Special Note: For a Covered Dependent child who has reached the end of the Calendar Year In which he or she becomes 26 and the Covered Dependent child obtains a dependent of their own (e.g., through birth or adoption), such newborn child will not be eligible for this coverage and cannot enroll. Further, such her eligibility for this coverage. Adopted Newborn Child — To enroll an adopted newborn child, the Covered Plan Participant must submit an Enrollment Form BCBSF during the 30-day period immediately following the date of birth. The Effective Date of for coverage, will be the moment of birth, Participant prior to the birth of such child, whether or not such an agreement Is enforceable. The Covered Plan Participant may be required to provide any information and/or . M107M after the birth of the child. If timely notice is not received, the applicable contribution will be charged from the date of birth, The applicable chan-gTal. afteTtTr;r initial 30-day period in either case. Coverage will not be denied for an adopted newborn child if the Covered Plan Participant provides notice Enrollment Form Is received within the 60-day period of the birth of the adopted newborn child and any applicable contribution is paid back to the date of birth. If the adopted newborn child is not enrolled Wil'al-a. Gi2ag 02%s if fl.r.0-4.2te *f kit'k, 110 '7141jiLi Enrollment and Effective Date of Coverage 11-2 newborn child will not be covered, and may only be enrolled under this Benefit Booklet during an Annual Open Enrollment Period, or in the case of a Special Enrollment event, during the Special Enrollment Period. If the adopted newborn child is not ultimately placed In the residence of the Covered Plan Participant, there shall be no coverage for the adopted newborn. child. It is your responsibility County BOCC Benefits Office within ten in your residence. AdoptediFoster Children To enroll an adopted or Foster Child, the Covered Plan Participant must submit an Enrollment Form during the 30-day period immediately following the date of placement. The Effective Gate for an adopted or Foster child (other than an adopted newborn child) will be the date such adopted or Faster child is placed In the residence of the Covered Plan Participant In compliance with applicable law. The Covered Plan Participant may be required to provide any Information and/or documents deemed necessary in order to properly administer this section. of placement so long as Covered Plan Participant provides notice to Monroe County BOCC Benefits Office, and we receive the Enrollment Form within 60 days of the placement. If the adopted or Foster Child is not enrolled within sixty days of the date of placement, the adopted or Foster Child will not Period. For all children covered as adopted children, if the final decree of adoption is not issued, coverage shall not be continued for the proposed adopted Child. Proof of final adoption must be submitted 3Ik .: � .�..F through Monroe County BODO Benefits Office. It is the notify BCBSF through Monroe County BODO Benefitsadoption doeso Upon receipt o:this notification, terminate the coverage of the child as of the of the written notice. .�. any Foster Child. It is ..' ..� - � of the � ' : �. C. through Monroe _ ■ BODO Benefits Plan Participant's care, Upon receipt of this notification, coverage for the child will be terminated an the date the Covered Plan Participant's status as a foster parent Marital Status —The Covered E.lan Participant due to a legally valid existing marriage under Federal Law. To apply for coverage, the Covered Plan Participant must complete the E. . Benefits Office and forwardE overed Plan Participant must make application for days of the marriage. The - '. of coverage fan Eligible or marriage is the date of the Dependent who Is enrolled as a result of completeCourt Order — The Covered Plan Participant may apply for coverage for an Eligible Dependent outside of the Initial Enrollment Period and Annual Open Enrollment Period if a minor child under their group coverage. To tie Covered-Rant-PaiVelFant must Monroe County ..i Benefits forward it to IIEY. IEIF EFCovered : an within 30 days of the court order, The Effective Enmilment and Effedve Date of Coverage 11.3 is enrolled as a result of a court order Is the date required by the court. Annual Open Enrollment Period Eligible Employees and/or Eligible Dependents Enrollment PeriodIa Special I I IIII I Enrollment IllOpen Enrollment Period. The Eligible Employee The effective date of coverage for an Eligible Employee and any Eligible Dependents) will be the state established by Monroe County BOC Benefits Office. Eligible Employees who do not enroll or change their coverage selection during the Annual Open Enrollment Period, must wait until the next Annual Open Enrollment Period, unless the Eligible Employee or the Eligible Dependent is enrolled due to a special circumstance as outlined in the Special Enrollment Period subsection of this section. An Eligible Employee and/or the Employee's Eligible Dependent(s) may apply for coverage outside of the Initial Enrollment Period and Annual Enrollment Period as a result of a special enrollment event. To apply for coverage, the Eligible Employee and/or the Employee's Eligible Dependent(s) must complete the applicable Enrollment Form and forward it to Monroe County BODC Benefits Office within the time periods noted below for each special enrollment event. An Eligible Employee and/or the Employee's Eligible Depandent(s) may apply for coverage if one of the following special enrollment events occurs and the applicable Enrollment Form i submitted to Monroe County BOED Benefits Office within the indicated time periods: If you lose your coverage under group health benefit plan (as an employee or dependent), or E ■ :nunder � .... of coverage under a d € 'wHealth #3 below), or COBRA continuation coverage that you were coveredEYEu the time of initial enrollment provided that: eligibility, a) when offered coverage under this plan at the time of initial ed in writing, .... coverage under u group health plan or health insurance coverage was the reason for declining enrollment; and b) you lost your other coverage under a roue health benefit insurance c. e .....sEE (except ofloss. coverage under P or deathMedicaid, see #3 below) as a result of termination of employment, reduction in the number of hours you work, reaching or exceeding the maximum lifetime of all benefits under other health coverage, the employer ceased offering group health coverage, divorce, legal separationemployer coveragecontributions toward such w Note:o. p. your required conhibution/prernium timely kas�� fair fraudulent claim or an intentional misrepresentation of a material fact in RIH I III I E � - ■ Enrollment and Rados Date of coverage t t -4 adoption or placement in anticipation of adoption and you submit the applicable Enrollment Form to Monroe County BOCC tb—adate-al-L the event. or 3. If you or your Eligible Dependents) lose coverage under a CHIP or Medicaid due to loss of eligibility for such coverage or become eligible for the optional state premium assistance program and you submit the applicable Enrollment Form to Monroe County SACO Benefits Office within 60 days of the date such coverage was terminated or the date you become eligible for the optional state premium assistance program. Eligible Dependents added as a result of a special enrollment event Is the date of the special enrollment event, Eligible Employees or their coverage selection during the Special Enrollment Period must wait until the next Annual Open Enrollment Period (See the Coverage Individuals who are rehired as employees of Monroe County BODO or any of the Constitutional Officers or their Employees are considered newly hired employees for purposes of this section. The provisions of the Group Health Plan (which includes this Booklet) which are applicable to newly hired employees and their Eligible Dependents (e.g., enrollment, Effective Dates of coverage, Pre-existing Condition exclusionary period, and Waiting their Eligible Dependents. Enrollment and Metro note of Coverage 1!-5 Participant's Coverage A Covered Plan Participant's coverage unde 1. on the date the Group Health Plan terminates; 2. an the date the ASO Agreement between BCBSF and Monroe County BOCC terminates; 3. on the last day of the first month that the Covered Plan Participant fails to continue to meet any of the applicable eligibility requirements; 4. an the date specified by Monroe County BOCC that the Covered Plan Participant's coverage is terminated for cause (see the Termination of an Individual Coverage for Cause subsection); or 5. an the date specified by Monroe County BOCC that the Covered Plan Participant's coverage terminates. Termination of a Covered Dependent's Coverage A Covered Dependent's coverage will automatically terminate at 12:01 a.m. on the date: 1. the Group Health Plan terminates; 2. the Covered Plan Participant's coveragip terminates for any reason; 3. the Dependent becomes covered under an alternative health benefits plan which is offered through or in connection with the Group Health Plan; 4. last day of the Calendar Year that the Covered Dependent child no longer meets any of the applicable eligibility requirements; 5. date speced by Monroe County SOCC that the Dependent's coverage is terminated for cause (see the Termination of Individual Coverage for Cause subsection). wish to delete a Covered Dependent from coverage, an Enrollment Form must be forwarded to BCBSF through Monroe County BOCC Benefits Office. wish to terminate a spouse's coverage, (e.g., In the case of divorce), you must submit an to the requested termination date or within 10 ............... hr;pl. RIM - Coverage for Cause County BOCC may terminate an individual's coverage for cause: 1. fraud, material misrepresentation or omission in applying for coverage or benefits; or 2. the knowing misrepresentation, omission or the giving of false information an Enrollment Forms or other forms completed, by or on your behalf. 1211mimmilk It is Monroe County BOCCA responsibility to 0 Terminagan at Coverage 12-1 M�M be issued to you. The certification of Creditable Coverage will V M IVLVI H LAU Plan. Creditable Coverage may reduce the length of any Pre-existing Condition Coverage will be sent to you within a 24-month Paden after termination of coverage. You may call the customer service phone number indicated in this Booklet or an your ID Card to request the certification. I - WIWI --- - Wix-MAAM I ARM determining if coverage meets the qualifying than a 63-day break in coverage). TerrninaVcn of Coverage 12-2 A federal continuation of coverage law, known as the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, may apply to your Group Health Plan. If COBRA applies, you or your Covered Dependents may be entitled to continue coverage for a limited period of time, if you meet the applicable requirements, make a timely election, and pay the proper amount required to maintain coverage, You must contact Monroe County BOCC Benefits Office to determine if you or your r, Covered Dependent(s) are entitled to COBRA -onflnuatlon of coverage. Monroe County obligaliIIIIIIIItions under COBRA, including the obligation to notify all CoveredyoPersons of their rights under COBRA. If u fail "il� meet yI�iour obligations under COBRA and this Benefit BOGG will not bIII IIe liabkk for any claims incurred by you or your Covered Dependent(s) after termination of coverage. A summary of your COBRA rights and the general conditions for qualification for COBRA continuation coverage is provided below. The following Is a summary of what you may elect, if COBRA applies to Monroe County PO and you are eligible for such coverage: 1. You may elect to continue this coverage a period not to exceed 18 months* in the case of: I a) termination of employment of the Covered Plan Participant other than for gross misconduct; or M reduced hours of employment of the Covered Plan Participant. *Note: You and/or your Covered Dependent(s) are eligible for an 11 month extension of the 18 month COBRA continuation option above (to a total of 29 months) if you or your Covered Dependent(s) is/are totally disabled (as 4- (SSA)h at the time of your termination, of COBRA continuation coverage. The Covered Person must supply notice of the disability determination to Monroe County BOCC Benefits Office within 18 months of 2. Your Covered Dependent(s) may elect to continue their coverage for a period not to exceed 36 months in the case at a) the Covered Plan Participant's entitlement to Medicare; b) divorce or legal separation of the Covered Plan Participant; c) death of the Covered Plan Participant; cp the employer files bankruptcy (subject to bankruptcy court approval); or a) a dependent child may elect the 36 month extension if the dependent child ceases to be an Eligible Dependent under the terms of Monroe County BOCC's coverage, Children born to or placed for adoption with the Covered Plan Participant during the continuation coverage periods noted above are also eligible for the remainder of the continuation period. Additional requirements applicable to continuation of coverage under COBRA are set forth below: 1. Monroe County SOCC must notify you of your continuation of coverage rights under COBRA within 14 days of the event which creates the continuation option. If coverage would be lost due to Medicare entitlement, ConUnuing Caverage Under COBRA 13-1 divorce, legal separation or the failure of a Covered Dependent child to meet eligibility requirements, you or your Covered Dependent must notify Monroe County BOCC Benefits Office, in writing, within 60 days of any of these events. Monroe County B®s 14-day notice requirement runs from the date of receipt of such notice. 2. You must elect to continue the coverage within 60 days of the later Of: a) the date that the coverage terminates; or M the date the notification of continuation of coverage rights is sent by Monroe County BOCC. 3. COBRA coverage will terminate if you become covered under any other group health insurance plan. However, COBRA coverage may continue if the new group health insurance plan contains exclusions or limitations due to a Pre-existing Condition that would affect your coverage. 4. COBRA coverage will terminate if you become entitled to Medicare. 5. If you are totally disabled and eligible and elect to extend your continuation of coverage, you may not continue such extension of coverage more than 30 days after a determination by the Social Security Administration that you are no longer disabled. You must Inform Monroe County BOCC Benefits Office of the Social Security Administration's determination within 30 days of such determination. 6. You must meet all contribution requirements, and all other eligibility requirements described In COBRA, and, to the extent not inconsistent with COBRA, in the Group Health Plan. 7. COBRA coverage will terminate on the date Monroe County BODO ceases to provide group health coverage to its employees. An election by a Covered Plan Participant or related to that Covered Plan Participant or Covered Dependent spouse, unless otherwise specified in the election form, Note: This section shall not be interpreted to grant any continuation rights in excess of those required by COBRA and/or Section 4980B of the Internal Revenue Code. Additionally, this Benefit Booklet shall be leeirel U-h2a2 sh2mkv interpreted, so as to comply with COBRA and changes to COBRA that are mandatory with respect to Monroe County BOCC. Conflnuing Coverage Under COBRA 13-2 1. you were continuously d for at least three months under the Group Health Plan, and/or under another group policy that provided similar benefits immediately prior to the Group Health Plan; and 2. your coverage was terminated for any Groupreason, including discontinuance of the Health Plan in its entirety and termination of continued coverage under Notify BCBSF in writing orby telephone interestedare .. a conversion policy. days of such notice, BCBSF will send you a conversion ..., notice and outline of coverage. The outline of coverage will contain a brief description benefits and coverage, exclusions and firriftations-and-theApplicable "' € =A '" Coinsurance provisions. for a converted policy, and the applicable premium payment, 'Y period Groupbeginning on the date the coverage under the coveragehasbeen terminated,due :. the non-payment of employee contribution by Monroe County SOCC, BCBSF must receive the completed converted policy application and the applicable premium payment within 3 # #. _E 4 period beginning on the date notice was given that the Group Health Plan converted In the event BCBSF does not receive the policy application premium payment within such 63-day period, your converted policy application will be denied E �. AI, F Medicare1. you are eligible for or covered under the 'gym 2. you failed to pay, on a timely basis, the contribution required for coverage under the Group Health Plan; 3. the .. Health replaced within group31 days after termination by any policy, contract, plan, or program, including or program,provides benefits similar to benefits provided under this Booklet; F 4. a) you fall under one of the following categories F meet M requirements ■ ■ you are i -' Hospital, surgical, medical or major medical policy or contract or under a prepayment plan or under any other plan or program th:x:' provides benefits which are similar to the benefits provided Booklet; you are eligible,'; not WINUMF€MR basis,or partially Insured benefits similar to those provided under this Booklet; or I benefits a to the benefits provided under this Booklet are provided for or are available to you pursuant to or in accordance with the requirements of any state or federal law (e.g,, COB Medicaid); and Convenlon F'Ovileg'a 141 b) the benefits provided under the sources referred to paragraph availablebenefits provided or r source referred to in paragraph 4.a.H. and 4.aJ1L above, together with the benefits provided E : d policy would result in over -insurance in accordance with our over -insurance standards, as determined b. us Neither Monroe County BOCC nor BCBSF has any obligation t# notify you of :.. terminatesconversion privilege when your coverage sole responsibility to exercise this converted policy application and the initial termination of your coverage under this Benefit ;.. Booklet. o€E : ,:. '' policy be Issued without evidence of Insurability and shall be effective the day following the terminated. Note: :r policies not continuation ofcoverage under COBRA B# identicalother states' similar laws. Coverage and benefits provided under a converted policy will not be # • " and benefits provided under this Booklet. When applying for o converted policy, p converted policy providing major medical coverage meeting the requirements of policy providing coverage and benefits identical to the coverage and benefits required to be provided under a small employer standard convertedhealth benefit plan pursuant to Section 627.6599(12) Florida Statutes. In any event, we will not be required to issue a unless required to do so by Florida law. We may p' other options to you. for rare inforination. Common PHvNew 14-2 Section 15: Extension of Benefits Extension of Benefits perform those normal day-to-day activities which you would otherwise perform and you In the event the Group Health Plan is terminated, coverage will not be provided under this Benefit Booklet for any Service rendered on or after the termination date. The extension of benefits provisions described below only apply when the entire Group Health Plan is terminated. The extension of benefits described in this section do not apply when your coverage terminates if the Group Health Plan remains in effect, The extension of benefits provisions are subject to all of the other provisions, including the limitations and exclusions. Note; It is your sole responsibility to provide acceptable documentation showing that you are entitled to an extension of benefits. 1. In the event you are totally disabled on the termination date of the Group Health Plan as a result of a specific Accident or illness incurred while you were covered under this Booklet, as determined by us, a limited extension of benefits will be provided under this Benefit Booklet for the disabled individual only. This extension of benefits is for Covered Services necessary to treat the disabling Condition only. This extension of benefits will only continue as long as the disability is continuous and uninterrupted. In any event, this extension of benefits will automatically terminate at the end of the 12- month period beginning on the termination date of the Group Health Plan. For purposes of this section, you will be considered 'totally disabled" only if, in our or Monroe County BOCCs opinion, you are unable to work at any gainful job for which you are suited by education, training, or experience, and you require regular care and attendance by a Physician. You are totally disabled only if, in our or Monroe County BOCC's opinion, you are unable to require regular care and attendance by a Physician. the event you are receiving covered dental treatment as of the termination date of the Group Health Plan a limited extension of such covered dental treatment will be provided under this Benefit Booklet ff: a) a course of dental treatment or dental procedures were recommended in writing and commenced in accordance with the terms specified herein while you were covered under the Group Health Plan; b) the dental procedures were procedures for other than routine examinations, prophylaxis, x-rays, sealants, or orthodontic services, and of the dental procedures were performed within 90 days after the Group Health Plan terminated. Services necessary to complete the dental treatment only. This extension of benefits will automatically terminate at the end of the 90-day period beginning on the termination date of the Group wff", covered under a succeedin * surance. TrVr%_W= insured plan providing coverage or Services for similar dental procedures. You are not required to be totally disabled in order to be eligible for this extension of benefits. Please refer to the Dental Care category of the 'What Is Covered?" section for a description of the dental care Services covered under this Booklet. Extension of Benefits 15-1 1 In the event you are pregnant as of the termination date of the Group Health Plan, a limited extension of the maternity expense benefits included in this Booklet will be available, provided the pregnancy commenced while the pregnant individual was covered under the Group Health Plan, as determined by us or Monroe County BOCC. This extension of benefits is for Covered Services necessary to treat the pregnancy only. This extension of benefits will automatically terminate on the date of the birth of the child. You are not required to be Totally Disabled in order to be eligible for this extension of benefits. Extension eft effis 15.2 continue to be eligible and covered Benefit Booklet, coverage under this Benefit Booklet E ■ - primary -Medicare benefits will be secondary, but only to the extent required by under this Benefit Booklet will be secondary to benefits under this Benefit Booklet are phmary, any Medicare benefits. To the extent the €A:f.3€O.ilM Under Medicare, Monroe County BOCC MAY NOT offer, subsidize, procure or provide a Medicare supplement policy to you. Also, iIF i i.............. .... .. 'u i .. m County W BOCC BenefitsOffice. :ELAM-I-K entitledIf you are i Ak b30 months eginning with - earlier of: entitled1. the month in which you became to bereffits, or i . AA INIOURIC14 a :■ xk MedicareIf primary prior eligiblebecame to EBRO, then Medicare Jr disability whoseemployer employees,and/or the age of 65). Also, if coverage under this Benefit Booklet was primary prior to ESRD entitlement, then is hereunder remain primary for i i' period. If you become eligible for Medicare due to EBRO, coverage be provided, as AY . ' i i€ # providedIf you are entitled to Medicare coverage because of a disability other than ESRD. Medicare berieffis will be secondary to the Calendarmore of its regular business days during the previous multi-employerPlan is a i by at least one employer participating In the plan on 50% or ■: of its regular during the =i a 1 . This section shall be subject to, modified (if necessary) to conform to or i and interpreted with reference to the requirements of federal statutory i regulatoryi Payer provisions as those provisions relate to Medicare beneficiaries who are covered i The Effect of Medicare Coveragal Medicare Secondary Payer Previsions is-1 2. BCBSF will not be liable to Monroe Coon SOCC or to any individual covered unde 'I r this Benefit Booklet on account of any nonpayment of primary benefits resulting i from any failure of performance of Moore County BOCC's obligations as described I I this section. The Effird of Medicare Coverage/ Medicare Secondary Payer Provisions 1&2 Coordination of ■e.e... ('COB") .... limitation I this Benefit Booklet. EYI � w iR will be paid program,than one health plan, providing benefits for Health Care Services. E A. . - to avoid.. costlyduplication of payment responsibility to provide ERE 3RBCBSF and Monroe County BOCC Benefits Office information concerning any duplication of coverage under sir, ER E . ER'E your w RlDependents means you ■ Monroe you County BOCC Benefits Office in writing if have other applicablecoverage or if there is no provideother coverage. You may be requested to this informationat initialenrollment, connection with a specific Health Care Service you receive. If the Information Is not received, claims may bedenied and M resp*ruilklep w to denied claims. subject B,BE ■ ■ E ■E include, but are not limited to, the following which will be referred to as .Van(s)" for purposes of this section, R RE RI' . EIR'w RR 3. any other plan, program or insurance policy, paymentincluding an automobile PIP insurance policy and/or medical coverage 'e'e Payer Provisions" section; and ■EEE. e'x E■ ■ a� The amountof payment, EE benefits basedare coordinated under this section, is whether E w not h benefits underBenefit Bookletprimary, payment will be made for Covered Services without regard to coverageunder Eotherplans. benefits under this Benefit Booklet are not R ■ R reduced ._>E so that total benefits ..... reasonable plans will not exceed 100 percent of the total expenses actually incurred for Covered Services.For purposes this section. an In -Network Provider or an Out-of-pletwork Provider EE_ participates ,■_ Program, "totalreasonable expenses" Provider E. Ed'applicable agreement ■. EF or another Blue Cross and/or Blue Shield organizationEsuch Provider. 1E.. .. e event E that Ex primarypayer'spayment exceeds the Allowed Amount,o payment will be made for such Services, _ E order benefitsunder R!"' RIEw :R' 1. When you are covered as Covered Dependent and the other plan covers you as Duplication a6 Caverage Under Other Health Plan rams 17-1 other than a dependent, the Group Health Plan will be secondary, 2. When the Group Health Plan covers a dependent child whose parents are not separated or divorced: a) the plan of the parent whose birthday, excluding year of birth, falls earlier in the year will be primary; or b) if both parents have the same birthday, excluding year of birth, and the other plan has covered one of the parents longer than us, the Group Health Plan will be secondary. 3. When the Group Health Plan covers a dependent child whose parents are separated or divorced: a) if the parent with custody is not remarried, the plan of the parent with custody is primary; 5. When rules 1, 2, 3, and 4 above do not establish an order of benefits, the plan which has covered you the longest shall be primary. The Group Health Plan will not coordinate benefits against an indemnity -type policy, an excess insurance policy, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy. 6If you are covered under a COBRA continuation plan as a result of the purchase of coverage as provided under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, and also under another group plan, the following order of benefits applies: a) first, the plan covering the person as an employee, or as the employee's Dependent; and b) if the parent with custody has remarried, the plan of the parent with custody is primary; the stepparent's plan Is secondary; and the plan of the parent without custody pays last; 7 c) regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child's health care expenses, the plan of that parent is primary, 4. When the Group Health Plan covers a dependent child and the dependent child is also covered under another plan: a) the plan of the parent who Is neither laid off nor retired will be primary; or b) if the other plan is not subject to this rule, and if, as a result, such plan does not agree on the order of benefits, this paragraph shall not apply. b) second, the coverage purchased under the plan covering the person as a former employee, or as the former employee's Dependent provided according to the provisions of COBRA. If the other plan does not have rules that establish the same order of benefits as I L under this Booklet, the benefits under the benefits u7nder this Booklet. Coordination of benefits shall not be permitted against an indernnity-type policy, an excess insurance policy as defined in Florida Statutes Section 627.635, a policy with coverage limited supplement policy. Programs and Worker's Compensation The benefits under this Booklet shall net .... . . . . . . . . . ..... Duplication of Coverage Under Other Health PlanslPrograrns 17-2 Malk:24, Veterams Aimix-listnidlom) or W*rker's Compensation to the extent allowed by law, or under any extension of benefits of coverage under a prior plan or program which may be provided or required by law. Duplication of Coverage Under Other Health Planaflarcorarns 17-3 Section 18: Subrogation In the event payment is made under this Benefit Booklet to you or on your behalf for any claim in connection with or arising from a Condition resulting, directly or indirectly, from an intentional act or from the negligence or fault of any third person or entity, Monroe County BOCC and/or the Group Health Plan, to the extent of any such payment, shall be suldrogated to all causes of action and all rights of recovery you have against any person or entity, Such subrogation rights shall extend and apply to any settlement of a claim, regardless of whether litigation has been Initiated. BCBSF may recover, on behalf of Monroe County BOCC and/or the Group Health Plan, the amount of any payments made on your behalf minus BCBSF or Monroe County BOCC's pro rate share for any costs and attorney fees Incurred by you In pursuing and recovering damages. BCBSF may subrogate, on behalf of Monroe County BOCC and/or the Group Health Plan, against all money recovered regardless of the source of the money including, but not limited to, uninsured motorist coverage. Although Monroe County BOCC may, but is not required to, take into consideration any special factors relating your specific case in resolving the subrogation claim, Monroe County BOCC will have the first right of recovery out of any recovery or settlement amount you are able to obtain even if you or your attorney believes that you have not been made whole for your losses or damages by the amount of the recovery or settlement. You must promptly execute and deliver such instruments and papers pertaining to such settlement of claims, settlement negotiations, or litigation as may be requested by BCBSF or Monroe County BC, and shall do whatever is necessary to enable BF or Monroe County BOCC to exercise Monroe County BOCC's subrogation rights and shall do nothing to prejudice such rights. Additionally, you or your y in writing of any settlement negotiations prior to entering Into any settlement agreement, shall disclose to BCBSF any amount recovered from not make any distributions of settlement or judgement proceeds without Monroe County BOCC's prior written consent. No waiver, Azd6gz w-tv oJi k-- k.- AlIgilms- r * t ho"d * *u annint o etie *UW by you without such notice to SCSSF shall be binding upon Monroe County BOCC. Subrogaflon 15-1 Section 19: Right of Reimbursement If any payment under this Benefit Booklet is made to you or on your behalf with respect to any injury or illness resulting from the Intentional act, negligence, or fault of a third person or entity, Monroe County BOCC and/or the Group Health Plan will have a right to be reimbursed by you (out of any settlement or judgment proceeds you recover) one dollar ($1.00) for each dollar paid under the terms of the Group Health Plan minus a pro rate share for any costs and attorney fees incurred in pursuing and recovering such proceeds, Monroe County BOCC's and/or the Group Health Plan's right of reimbursement will be In addition to any subrogation right or claim available to Monroe County BOCC, and you must execute and deliver such instruments or papers pertaining to any settlement or claim, settlement negotiations, or litigation as may be requested by BCBSF on behalf of Monroe exercise Monroe County BOCC's and/ or the Group Health Plan's right of reimbursement hereunder. You or your lawyer must notify us, by certified or registered mail, if you intend to claim damages from someone for injuries or illness. You must do nothing to prejudice Monroe County BOCC's and/or the Group Health Plan's right of reimbursement hereunder and no waiver, release of liability, or other dnr,�waaoJs—Px.prjjJnrLhy and our written consent, acting an behalf of Monroe County BOCC, will be binding upon Monroe County SOCC. Rnhf of Reimbursement 19-1 Section 20: Claims Processing This section is intended to: help you understand what you or your treating Providers must do, under the terms of this Benefit Booklet, in order to obtain payment for expenses for Covered Services they have rendered or will render to you; and provide you with a general description of the applicable procedures we will use for making Adverse Benefit Determinations, Concurrent Care Decisions and for notifying you when we deny benefits. Under no circumstances will we be held responsible for, nor will we accept liability relating to, the failure of your Group Plan's sponsor or plan administrator to: 1) comply with any applicable disclosure requirements; 2) provide you with a Summary Plan Description (SPD); or 3) comply with any other legal requirements. You should contact your plan sponsor or administrator if you have questions relating to your Group Plan's SPD. We are not your Group Plan's sponsor or plan administrator, In most cases, a plan's sponsor or plan administrator is the employer who establishes and maintains the plan. Types of Claims For purposes of this Benefit Booklet, there are three types of claims: 1) Pre -Service Claims; 2) Post -Service Claims-, and 3) Claims Involving Urgent Care. It Is important that you become familiar with the types of claims that can be submitted to us and the firnefrarnes and other requirements that apply. Post -Service Claims How to File a Post -Service Claim We have defined and described the three types of claims that may be submitted to us. Our experience shows that the most common type of claim we will receive from you or your treating Providers will likely be Post -Service Claims. In -Network Providers have agreed to file Post - Service Claims for Services they render to you. In the event a Provider who renders Services to you does not file a Post -Service Claim for such Services, it is your responsibility to file it with us. We must receive a Post -Service Claim within 90 days of the date the Health Care Service was rendered or, if it was not reasonably possible to file within such 90-day period, as soon as possible. In any event, no Post -Service Claim will be considered for payment if we do not receive it at the address indicated on your IS Card within one year of the date the Service was rendered unless you were legally incapacitated. For Post -Service Claims, we must receive an itemized statement from the health care Provider for the Service rendered along with a completed claim form, The itemized statement must contain the following information: 1. the date the Service was provided; 2. a description of the Service including any applicable procedure canals); 3. the amount actually charged by the Provider; 4. the diagnosis including any applicable diagnosis code(s); S. the Provider's name and address-, • the name of the individual who received the Claims Processing 20-1 the Covered Plan Participant's name and contract number as they appear on the ID Card. The itemized statement and claim form must be received by us at the address indicated on your I D Card. Note: Special claims processing rules may apply for Health Care Services you receive outside the state of Florida under the BlueCard Program (See the 'BlueCard (Out -of -State) Program" section of this Booklet). The Processing of Post -Service Claims We will use our best efforts to pay, contest, or deny all Post -Service Claims for which we have all of the necessary Information, as determined by us. Post -Service Claims will be paid, contested, or denied within the timefirames described below. 0 Payment for Post -Service Claims When payment is due under the terms of this Benefit Booklet, we will use our best efforts to pay (in whole or in part) for electronically submitted Post -Service Claims Within 20 days of receipt. Likewise, we will use our best efforts to pay (In whole or in part) for paper Post -Service Claims within 40 days of receipt. You may receive notice of payment for paper claims within 30 days of receipt. If we are unable to determine whether the claim or a portion of the claim is payable because we need more or additional Information, we may contest the claim within the firrieframes set forth below. a Contested Post -Service Claims In the event we contest an electronically submitted Post -Service Claim, or a portion of such a claim, we will use our best efforts to provide notice, within 20 days of receipt, that the claim or a portion of the claim Is contested, In the event we contest a Post -Service Claim submitted on a paper claim form, or a portion of such a claim, we will use our best efforts to provide notice, within 30 days of receipt that the claim or a portion of the claim is contested. Our notice may Identify: 1) the contested portion or portions of the claim, 2) the reason(s) for contesting the claim or a portion of the claim; and 3) the date that we reasonably expect to notify you of the decision. The notice may also indicate whether additional information Is needed in order to complete processing of the claim. If we request additional information, we mwet-Feceive itwvith�n 45 iay,3 �-mquest fu_ the information. If we do not receive the information In our possession at the time and may be denied, Upon receipt of the requested information, we will use our best efforts to complete the processing of the Post - Service Claim within 15 days of receipt of the information. �03 IMA, ff "1111111IRM&MITOMMEM In the event we deny a Post -Service Claim submitted electrIIII onically, we will use our best efforts to provide notice, within 20 days of recei,--- - that the claim r a portion of the claimis -Venied. In the event we deny a paper Post - Service Claim, we will use our best efforts to claim or a portion of the claim is denied. The notice may identify the denied portion(s) of the claim and the reason(s) for denial. It is your responsibility to ensure that we receive all information determined by us as necessary to adjudicate a Post -Service Claim. If we do not reovive Veg xectssmW tke 0--mhu tr a portion of the claim may be denied. — F-11119MISOMM M-1110r, 11MMITINHIMEM MW appeal procedures described In this section. pintill -- - - - - ......... .... wrawfinangm J� if or deny all: 1) electronic Post -Service Claims ILE Claims P=essinq M-2 and 2) Post -Service paper claims within 120 days of receipt of the completed claim. Claims processing shall be deemed to have been completed as of the date the notice of the claims decision is deposited In the mail by us or otherwise electronically transmitted. Any claims payment relating to a Post -Service Claim that Is not made by us within the applicable timeframe is subject to the payment of simple interest at the rate established by the Florida Insurance Code. We will Investigate any allegation of improper billing by a Provider upon receipt of written notification from you. If we determine that you were billed for a Service that was not actually performed, any payment amount will be adjusted and, if applicable, a refund will be requested. In such a case, if payment to the Provider is reduced due solely to the notification from you, we will pay you 20 percent of the amount of the reduction, up to a total of $500. Pre -Service Claims How to File a Pre -Service Claim This Benefit Booklet may condition coverage, benefits, or payment (in whole or in part), for a specific Covered Service, on the receipt by us of a Pre -Service Claim as that to is defined herein. In order to determine whether we must receive a Pre -Service Claim for a particular Covered Service, please refer to the 'What Is Covered?" section and other applicable sections of this Benefit Booklet. You may also call the customer service number on your ID card for assistance. We are not required to render an opinion or make a coverage or benefit determination with respect to a Service that has not actually been provided to you unless the terms of this Benefit Booklet require (or condition payment upon) approval by us for the Service before it is received. involving Urgent.Care For a Pre -II II illService Claim Involving Urgent Care, we will use our best efforts to provide notice of our determination (whether adverse or not) as soon as possible, but not later than 72 hours after receipt of the Pre -Service Claim unless decision. If additional information is necessary to make a determination, we will use our best efforts to provide notice within 24 hours of: 1) the need for additional information; 2) the specific Information that you or your Provider may need to provide; and 3) the date that we reasonably expect to provide notice of the decision. If we request additional information, we must receive it within 48 hours of our request. We will use our best efforts to provide within 48 hours after the earlier of: 1) receipt of the requested information, or 2) the end of the period you were afforded to provide the specified additional information as described above. that Do Not frivol t Care decision on a III Claim not involving urgent care within 15 days of receipt provided additional information is not required for a coverage decision. This 15-day determination an additional 15 days. If such an extension is notice of the extension and reasons for it, We the decision on your Pre -Service claim within a If additional information Is necessary to make a determination, we will use our best efforts to: 1) provide notice of the need for additional information, prior to the expiration of the initial Claims Pmeassing 20-3 that you or your Provider may need to provide; and 3) inform you of the date that we reasonably expect to notify you of our decision. If we request additional information, we must receive it within 45 days of our request for the information. We will use our best efforts to provide notification of the decision on your Pre - Service Claim within 15 days of receipt of the requested information. A Pre -Service Claim denial is an Adverse Benefit Determination and is subject to the appeal procedures described in this section. Concurrent Care Decisions Reduction or Termination of Coverage or Benefits for Services A reduction or termination of coverage or benefits for Services will be considered an Adverse Benefit Determination when: we have approved in writing coverage or benefits for an ongoing course of Services to be provided over a period of time or a number of Services to be rendered, and 0 the reduction or termination occurs before the end of such previously approved time or number of Services; and 9 the reduction or termination of coverage or benefits by us was not due to an amendment of this Benefit Booklet or termination of your coverage as provided by this Benefit Booklet. We will use our best efforts to notify you of such reduction or termination in advance so that you will have a reasonable amount of time to have accordance with the Adverse Benefit Determination standards and procedures described below. In no event shall we be required to provide more than a reasonable period of time within which you may develop your appeal before we actually terminate or reduce coverage for the Services. . . . . . . . . . . . . . a r Provider may request an extension of coverage or benefits for a Service beyond the approved period of time or number of approved Services. If the request for an extension Is for a Claim Involving Urgent Care, we will use our of such requested extension within 24 hours after receipt of your request, provided it is received at least 24 hours prior to the expiration of the previously approved number or length of coverage for such Services. We will use our yux wth" 24 h*m-s-& 1 �wa need additional information; or 2) you or your re-A.-resentatrira faited tia fishw ur*�eT-pr,#ua4xrac'- in your request for an extension. If we request additional information, you will have 48 hours to provide the requested Information. We may notify you orally or in writing, unless you or your representative specifically request that it be in writing. A denial of a request for extension of Services is considered an Adverse Benefit Determination and is subject to the Adverse Benefit Determination review procedure below. Determinations .. . ............. Adverse Benefit Determination: We will use our best efforts to provide notice of any Adverse Benefit Determination in writing. of charge upon request): IMITZ-7 ME Moms= 4. the diagnosis codes included on the claim DSM-IV), including a 5the standardized procedure code included on the claim (e.g., Current Procedural Claims Processing 20-4 Terminology), including a description of such codes; 6. the specific reason or reasons for the Adverse Benefit Determination, including ZZEIME��� 7a description of the specific Benefit Booklet provisions upon which the Adverse Benefit Determination Is based, as well as any internal rule, guideline, protocol, or other similar criterion that was relied upon in making the Adverse Benefit Determination', 8. a description of any additional Information that might change the determination and why that information is necessary, 9. a description of the Adverse Benefit Determination review procedures and tho time limits applicable to such procedures; 10. if the Adverse Benefit Determination is based on the Medical Necessity or Experimental or Investigational limitations and exclusions, a statement telling you how to obtain the specific explanation of the scientific or clinical judgment for the determination; and 11 . You have the right to an independent external review through an external review organization for certain appeals, as provided in the Patient Protection and Affordable N;I1111111110461mm. If the claim is a Claim Involving Urgent Care, we may notify you orally within the proper timeframes, provided we follow-up with a written or electronic notification meeting the requirements of this subsection no later than three days after the oral notification. Wifitea-u1nation Except as described below, only you, or a representative designated by you in writing, have the right to appeal an Adverse Benefit ........ ........ ........ process described below. Your appeal must be submitted to us in writing for an internal appeal within 365 days of the original Adverse Benefit circumstances, require you to file within a shorter period of time from notice of the denial. The following guidelines are applicable to reviews of Adverse Benefit Determinations: a. You may request to review pertinent documents, such as any internal rule, W"'ili-S 11111 1, or s4tilar criteriolt relied 11111tilift issues or comments in writing; If the Adverse Benefit Determination Is 1005� particular Service or the Experimental or br,v-P-s14QlJxx&l imclusiox ys-.,Lvgy ireqiesC free of charge, an explanation of the During the review process, the Services in question will be reviewed without regard to the decision reached in the initial determination-, We may consult with appropriate Physicians, as ne..essary-, If your claim is a Claim Involving Urgent Care, you may request an expedited appeal' orally or in writing in which case all necessary information an review may be transmitted between you and us by telephone, facsimile or other available expeditious method: and Claims Processing 20-5 on your behalf, we must receive a completed Appointment of Representative form signed by you indicating the name of the person who will represent you with respect to the appeal. An Appointment of Representative form is not required if your Physician is appealing an Adverse Benefit Determination relating to a Claim Involving Urgent Care. Appointment of Representative forms are available at www.Roddablue.com or by calling the ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . moo= Benefit Determinations We will use our best efforts to review your communicate the decision in accordance with the following time frames: receipt of your appeal; or MUM, receipt of your appeal, or Claims Involving Urgent Care (and requests to extend concurrent care Services made within 24 hours prior to the termination of the Services)— within 72 hours of receipt of your request. If additional Information is necessary we will notify you within 24 hours and we must receive the requested additional information within 48 hours of our request. After we receive the additional information, we will have an additional 48 hours to make a final determination. Note, The nature of a claim for Services (i.e. whether it is "urgent care" or not) Is judged as of the time of the benefit determination on review, not as of the time the Service was initially reviewed or provided. You, or a Provider acting on your behalf, who has had a claim denied as not Medically Necessary has the opportunity to appeal the to exceed 15 business days. Requests for an 4Vriri I NAPA Attention: Member Appeals P.O. Box 44197 Jacksonville, Florida 32231-4197 Our Appeati Decision your appeal of an Adverse Benefit Determination, please refer to the Adverse review, I ITT` ProvisioTry; IiIIIIIIIIIIM In order to process claims, we may need certain information, including information regarding other health care coverage you may have. You must cooperate with us in our effort to obtain such Information by, among other ways, signing any release of information form at our request, Failure by ..... ..... no liability for such claim. Z Physical Examination: In order to make coverage and benefit decisions we me 111 - you to be examined by a health care Provider of our choice as often as is reasonably necessary while a claim is pending. Failure by you to fully cooperate colms Processhg 2M with such examination shall result In a denial of the pending claim and we shall have no liability for such claim. 3. Legal Actions, No legal action arising out of or in connection with coverage under this Benefit Booklet may be brought against us within the 60-day period following our receipt of the completed claim as required herein. Additionally, no such action may be brought after expiration of the applicable statute of limitations. 4. Fraud, Misrepresentation or Omission in Applying for Benefits: We rely an the information provided on the itemized statement and the claim form when processing a claim. All such information, therefore, must be accurate, truthful and complete. Any fraudulent statement, emission or concealment of facts, misrepresentation, or incorrect information may result, in addition to any other legal remedy we may have, in denial of the claim or cancellation or rescission of your malwom 5. Explanation of Benefits Form: All claims decisions, including denial and claims review decisions, will be communicated to you in writing either an an explanation of benefits form or some other written correspondence. This form may indicate: a) The specific reason or reasons for the Adverse Benefit Determination-, b) Reference to the specific Benefit Booklet provisions upon which the Adverse Benefit Determination is based as well as any internal rule, guideline, protocol, or other similar criterion that was relied upon in making the Adverse Benefit Determination', W A description of any additional information that would change the initial determination and why that information is necessary; A) A description of the applicable Adve Benefit Determination review procedures and the time limits applicable to such procedures; and a) If the Adverse Benefit Determination is based an the Medical Necessity or Experimental or Investigational limitations and exclusions, a statement telling you how you can obtain the specific explanation of the scientific or clinical judgment for the determination. Ls� To the extent that natural disaster, war, do civil Insurrection, epidemic, or other emergency or similar event not within our control, results in facilities. personnel or on financial resources being unable to proces 'ava c4lems t-, C*Yere-I Servfices, we v*hRwroa liability or obligation for any delay in the payment of claims for Covered Services, except that we will make a good faith effort to make payment for such Services, taking into account the imnact of the eye purposes of this pa ragraph, an event is not within our control if we cannot effectively exercise influence or dominion over its occurrence or tot-occur netc e. Claims Processing 20.7 Neither BCSSF nor Monroe County BOCC nor any of their officers, directors or employees provides Health Care Services to you, Rather, in 1-1-177ingcoverage 7115 . #x... this Booklet. By accepting the Group health makingcare coverage and benefits, you agree that such coverage # benefit o . renderingServices and that health care Providers those employees agents of BCBSF or Monroe County BOCC. In this regardwe and Moe,...■. County SOCC hereby expresslydisclaim any agency relationship,actual or implied, health t -Provider. � 3F we €, # Monroe County BOCC do not, by virtue of making coverage, medicalexercise any control or direction over the - decisions of any health care Provider. Any decisions made under the Group Health Service is Medically Necessary, shall be 3� x x :.. # # arvices, are covM and not for purposes of recommending any # Na�iiri-&--CBSF nu CountyMonroe _ liability for �F _#.s _ omissions q, any Provider. County .. a '3Y:,O :.,,...,, Neither nor any person coveredunderBooklet BCBSF's agent or employees,a..Atp or omissions bi��i;ELC-E-s-agents--senLe-n,*_ or Additionally,B. B ' contractin tort or otherwise, for omissions of any other person or organization E � Coveredarrangements for the provision of representativeServices. BCBSF is not your agent, servant, o representative nor is BCBSF an agent, servant or of BOCC and acceptanceBCBSF will not be liable for any acts or agents, servants, employees, or any person or organization with which Monroe County BOCC, By hereunder, you agree to the foregoing. Decisions Medical Treatment w= 3Y PhysicianAny and all decisions that require or pertain to independent professional medical judgment or training, or the need for medical Services or supplies, must be made solely by your family and your treating with the patient1physician relationship. It is possible that y�jrx or �*vr treating Physician may ctnOwfie that a particular procedure is needed, appropriate, or desirable, even though such procedure may not be covered. ReWonship Behmean to Pia 21-1 BCBSF and Monroe County BOCC have the right to receive, from you and any health care Provider rendering Services to you, Information that is reasonably necessary, as determined by BCBSF and Monroe County BOCC, in order to administer the coverage and benefits provided, subject to all applicable confidentiality requirements listed below. By accepting coverage, you authorize every health care Provider who renders Services to you, to disclose to BCBSF and Monroe County SOCC or to affiliated entities, upon request, all facts, records, and reports pertaining to your care, WMG-t�.■ Lut-"A "ta-C"-dLiketw, ax—vi to permit BCBSF and/or Monroe County BOCC to copy any such records and reports so obtained. Right to Receive Necessary Information ft-corhsm�--- � or notice to an W-,ersm plan, or organization, obtain from any person, plan, or person covered under this Booklet or applicant �o■ IkTwKWC3CM'—*r lYsi-w%v4sw-rit�r BOCC deem to be necessary, Whenever the Group Health Plan has made for under this Booklet, BCBSF or Monroe awimty 15CC-C wftrdrethe-right 4-reucnvir any such payments, to the extent of such excess, from you or any person, plan, or other organization that received such payments. W11119I liIl— KIM M-111I and Regulations The tenns of coverage and benefits to be provided under this Benefit Booklet shall be deemed to have been modified and shall be WZWW or federal laws and regulations dealing with benefits, eligibility, enrollment, termination, or other rights and duties. wm�w administer coverage and benefits, specific Providers, shall be kept confidential by us in conformity with applicable law. Such information may be disclosed to third parties for use In connection with bona fide medical research and education, or as reasonably necessary in connection with the administration of coverage and benefits, specifically including BCBSF's quality assurance and Blueprint for Health Programs. Additionally, we may disclose such information to entities affiliated with us or other persons or entities we utilize to assist in providing coverage, benefits or services under this Booklet. Further, any documents or information which are properly subpoenaed in a judicial proceeding, or by order of a regulatory agency, shall not be subject to this provision. require that we release certain claims and medical information about persons covered under this Booklet to that Provider even it txemm et*has ri*t-bten soujvhK W.-y-cii-timi-gh that Provider. By accepting coverage, you hereby authorize us to release to Providers claims information, includin related medical Jr such Provider to evaluate your financial responsibility under this Booklet. General Proyislans 22-1 You have been provided with this Benefit .9 of your coverage under this Benefit Booklet. the Participation Status NetwomBlue and the Traditional Provider Program, and the participation status of individual Providers available through BCBSF, are subject to change at any time by BCBSF without prior notice to you or your approval or that of Monroe County BOCC. Additionally, BCBSF may, at any time, terminate or modify the terms of any Provider contract and may enter into addonal Provider contracts without prior notice to you, or your approval or that of Monroe County BOCC. It is your responsibility to determine whether a health care Provider is an In -Network Provider at the time the Health Care Service is rendered. Under this Booklet, upon a Provider's participation status. I M.1 1 F 1 1 Wi us any consents, releases. assignments, and other documents requested in order to administer, and exercise any rights hereunder. Failure to do so may result in the denial of Coverage for Cause subsection in the Termination Of Coverage section), require the strict adherence to any of the terms or condons described herein, will in no event constitute a waiver of any such terms or conditions. Furl .... I *I Monroe County BOCC's right at any time to enforce any terms or conditions under this Benefit Booklet. W-Alm., WMI - by United States Mail, postage prepaid, and addressed as listed below. Sur4 intiro will 'to . . . . . . . . . . . . . depositedin the mail. Card. If to you: To the latest address provided by you or to your latest address on Enrollment Forms Benefits Office Immediately of any address change, Upon termination of your coverage for any reason, there wil I be no further liability or Plan, except as sgecificallX described herein, No oral statements, representations, or delete , add, or otherwise modify the express written terms of this Booklet. General PrWs�ans Z2-2 ..... .. .. ... F NIHIPINST-10 lit V lt The performance outcome and financial data published by the Agency for Health Care Administration (AHCA), pursuant to Florida Statute 408,05, or any successor statute, located at the web site address woronfloridahealtrif Mder.c ov, may be accessed a_ 4w"191111-1A Blue Shield of Florida corporate web site at www.floridablue.com. The terms and provisions of the Grou"eafth Plan shall be binding solely upon, and inure solely to the benefit of, Monroe County BOCC any rights, interest or claims thereunder, or under this Benefit Booklet I or be titled to sue or otherwise. Monroe County BOCC hereby Providers that have not entered into contracts wtth N155F ts ?I-ravidev- networks shall not be third -party beneficiaries under the terms of the Monroe County BOCC Group Health Plan or this Benefit Booklet. a-101110-11tt-DROX-111 A ' V terms of the program. We will tell you about any member newsletters and/or on our websiter. Your participation in these programs is comA letely voluntary and will In no way affect BookleL We reserve the right to offer rewards in excess of $25 per year as well as the right to discontinue or modify any reward program features or promotional offers at any time without your consent. General Provisions 22-3 Booklet. Other definitions may be found in the particular section or subsection where they are used. A 3111M event, other than the acute onset of a bodily injury. This term does not Include Injuries Accidental Dental Injury means an injury to sound natural teeth (not previously compromised by decay) caused by a sudden, unintentional, and unexpected event or force. structures within the oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a disease or illness. Administrative Services Only Agreement or Monroe County BODO and BCBSF. Under the Administrative Services Only Agreement, BCBSF provides claims processing and payment services, customer service, utilization review sowices aid access to BCBSF's Traditional Insurance Providers. Adverse Benefit Determination means any denial, reduction or termination of coverage, EN S ed in ",zZ, qpnfl Adverse Benefit Determination, Allowed Amount means the maximum amount upon whiIIIII ch payment will be based for Covered Services. The Allowed Amount may be changed at any time without notice to you or your consent. 1 . In the case of an In -Network Provider located in Florida, this amount will be established in accordance with the applicable agreement between that Provider and BCBSF. 2. In the case of an In -Network Provider located outside of Florida, this amount will generally be established in accordance with the negotiated price that the on -site Blue Cross and/or Blue Shield Plan ('Host Blue") passes on to us, except when the Host Blue Is unable to pass an its negotiated price due to the terms of its Provider contracts. See the BlueCard (Out -of -State) Program 3. In the case of Out-of-bletwork Providers located in Florida who participate In the Traditional Program, this amount will be established in accordance with the applicable agreement between that Provider and BCBSF. 4In the case of Out -of -Network Providers located outside of Florida who participate in the BlueCard (Out -of -State) Tradonal Program, this amount will generally be established In accordance with the negotiated price that the Host Blue passes on to us, except when the Host Blue Is unable to pass on its negotiated price due to the terms of its Provider contracts. See the BlueCard (Out -of -State) Program section for more details. & In the case of an Out-of-pletwork Provider that has not entered Into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider for the specific Covered Services provided to you, the Allowed Amount will be the lesser of thai Provider's actual billed amount for the specific Covered Services or an amount established by BCBSF that may be based on several factors including (but not Definiflans 23-1 necessarily limited to): (1) payment for such Services under the Medicare and/or Medicaid programs; fit payment often accepted for such Services by that Out -of - Network Provider and/or by other Providers, either in Florida or in other comparable markeds), that BBB determines are comparable to the Out-of-hetwork Provider that provided the specific Covered Services (which may include payment accepted by such Out -of -Network Provider and/or by other Providers as participating providers in other provider networks of third -party payers which may include, for example, other insurance companies and/or health maintenance organizations), (III) payment amounts which are consistent, as determined by BCBSF, with BCBSF's provider network strategies (e.g., does not result in payment that encourages Providers participating in a BCBSF network to become non -participating); and/or, (Iv) the cost of providing the specific Covered Services. In the case of an Out-of-bletwork Provider that has not entered into an agreement with another Blue Cross and/or Blue Shield organization to provide access to discounts from the billed amount for the specific Covered Services under the Blue and (Out - of -State) Program, the Allowed Amount for the specific Covered Services provided to you may be based upon the amount provided to BCBF by the other Blue Cross and/or Blue Shield organization where the Services were provided at the amount such organization would pay non -participating Providers in its geographic area for such Services. Please specifically note that, in the case of an Out -of -Network Provider that has not entered into an agreement with BF to provide access to a discount from the billed amount of that Provider, the Allowed Amount for particular Services is often substantially below the amount I -XIM14 Services. You will be responsible for any difference between such Allowed Amount and Out -of -Network Provider. Ambulance means a ground or water vehicle, to Chapter 401 of the Florida Statutes, or a similar applicable law in another state. Florida Statutes, or a similar applicable law of provide elective surgical care to a patient, admitted to, and discharged from such facility within the same working day. ■ modifications, using behavioral stimuli and consequences to produce socially significant improvement In human behavior, including, but not limited to, the use of direct observation, measurement and functional analysis of the relations between environment and behavior. procedure in which sperm is placed into the 0 01K 10 NERHEWN Diseases, Ninth Edition, Clinical Modification (ICIB-9 CM), or their equivalents in the most recently published version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders: 1. Autistic disorder; 2. Asperger's syndrome-, 3, Pervasive developmental disorder not otherwise specified; and 4. Childhood Disintegrative Disorder. Definifions 2-3-2 benefitsBenefit Period means a consecutive period of time, specified by BCBSF and the Group, in which satisfaction of Deductibles, out-of-pocket maximums and any applicable benefit maximums. Your Benefit Period is listed on your Schedule of Benefits, and will not be less than 12 months unless indicated as such. Birth Center means a facility or institution, other than a Hospital or Ambulatory Surgical Center, which is properly licensed pursuant to Chapter 383 of the Florida Statutes, or a similar applicable lave of another state, in which births are planned to occur away from the mother's usual residence following a normal, uncomplicated, low -risk pregnancy. BlusCard (Out -of -State) Program means a program available through Blue Cross and Blue Shield of Florida, Inc. Subject to any applicable BlueCard (Out -of -State) Program rules and protocols, you may have access to the Provider Blue Shield plans. See the BlueCard (Out -of - State) Program section for more details. Blue and (Out -of -State) PPO Program means a national Blue Cross and Blue Shield Association program available through Flue Cross and Blue Shield of Florida, Inc. Subject to any applicable Blue and (Out -of -State) Program roles and protocols, you may have access to the BlueCard (Out -of -State) PPO Program discounts of other participating Blue Cross anchor Blue Shield plans. BT9UGUTRU917iPf means a national Blue Cross and Blue Association program availablethrough Blue Cross and Blue Shield of Florida, Inc. Subject to rules and pralloccits-Was-may have access to the BlueCard (Out -of -State) Traditional Program discounts of other participating Blue Cross and/or Blue Shield plans. BlueCard (Out -of -State) PPO Program Provider ide BlueCard (Out -of -State) PPO Program Provider by the Host 70' Provider designated as a "' ■'Traditional Blue.Provider by the Host � : ,: �- I precursor cells administered to patient to curativefunctions following ablative or non -ablative therapy with oke-prolonging intent. bloodHuman obtained patientfrom the . s transplant, or an allogeneic transplant from a medically be derivedmarrow, blood, or a combination of bone marrow d part of the treatment involving bone marrow transplantation, the term "Bone ow administrationTransplant" includes the transplantation as well as the p and the chemotherapy drugs. The term "Bone Marrow Transplant" also includes any Services or supplies relating to any treatment or therapy and includes any and all Hospital, Physician o which are rendered of, or comolications arkeno from the use f hiah blood precursor cells (e.g., Hospital room and board and ancillary Services), Calendar y 1 Eenda December 31 at. providedunder the supervision of a Wx: ysicist or an appropriate Provider trained for Cardis Therapy, for the purpose of aiding in the restoration of normal heart function in I Definidons 23-3 connection with a myocardial infarction, coronary occlusion or coronary bypass surgery. Certified Nurse Midwife means a person who is licensed pursuant to Chapter 464 of the Florida Statutes, or a similar applicable law of anntrwr elam- as an advanced nurse nractitioner American College of Nurse Midwives. Certified Registered Nurse Anesthetist means a person who is a properly licensed nurse who Is a certified advanced registered nurse practitioner within the nurse anesthetist category pursuant to Chapter 464 of the Florida Statutes, or a similar applicable law of another state. Claim Involving Urgent Care means any request or application for coverage or benefits for medical care or treatment that has not yet been provided to you with respect to which the application of time periods for making rem - urgent care benefit determinations: (1) could seriously jeopardize your life or health or your ability to regain maximum function; or (2) in the opinion of a Physician with knowledge of your Condition, would subject you to severe pain that cannot be adequately managed without the proposed Services being rendered. Coinsurance means your share of health care expenses for Covered Services. After your Deductible requirement is met, a percentage of the Allowed Amount will be paid for Covered Services, as listed in the Schedule of Benefits. The percentage you are responsible for is your Coinsurance. by us to deny, reduce, or terminate coverage benefits, or payment (in whole or in part) with over a period of time, or a specific number of treatments, if we had previously approved or authorized in writing coverage, benefits, or of treatments. shall not include any decision to deny, reduc or terminate coverage, benerits, or payment as described In the 'Blueprint For Health Programs" section of this Benefit Booklet. to =11 E E. Mftm JOMW injury, or pregnancy, Convenient Care Center means a property licensed ambulatory center that: 1) treats a limited number of common, low -intensity illnesses when ready access to the patient's primary physician is not possible; 2) shares RMN In a retail business; and 4) is staffed by at least one masters level nurse (ARNP) who operates under a set of clinical protocols that strictly circw--mscdWe the conAg#ns the ARWF can trea4_ Although no physician is present at the Convenient Care Center, medical oversight is based on a written collaborative agreement 4WkW*d,J2R&VJ A Yt Copayment means the dollar amount established solely by BCBSF and Monroe County BOCC which is required to be paid to a health care Provider by you at the time certain . . . . . . . . . . . . . Cost Share means the dollar or percentage runautt astablis4ed soleiv dv, us. inVick must be Cost Share may include, but Is not limited to Admission Deductible (PAD) amounts. Apoic"le Cost S�Ivre anntuxts 2re, 111-extiffeit im your Schedule of Benefits. Covered Dependent means an Eligible applicable eligibility requirements and who Is earollel, 2*4 aCtU211Y Olverel, uavier tke Grit -up Health Plan other than as a Covered Plan 129il6maal"Asm"Re 1i12WdtL__dhA1iFJ "* DefiniVons 23-4 Dependenbsy subsection of the "Eligibility for Coverage' section). Covered Person means a Covered Plan Participant or a Covered Dependent. Covered Plan Participant means an Eligible Employee or other individual who meats and continues to meet all applicable eligibility requirements and who is enrolled, and actually covered, under this Benefit Booklet other than as a Covered Dependent. Covered Services means those Health Care Services which meet the criteria listed in the 'What Is Covered?" section. Custodial or Custodial Care means care tIIL hat serves to assist an individual in the activities of daily living, such as III assistance in walking, getting in and III out of bed, bathingIIII III II II, dIIII ressIIIIing, feedinII g, and usinII II II II IIII II II g the toilIIIet, preparatiIIII Ion of special diets, and supervision ogullf me��Idication that usually can be self-administered. Custodial Care essentially is personal care that does not .require the continuing attention of trained medical or paramedical personnel. In IIII -determining whether a person Is receiving Custodial CareII II, conII sideraII III IIII tion is giIII 1 II ven to the frequency, intensitII y and level of carIIII e and medical supervision required and furnished, A determination that care received is Custodial is not based an the pailatienCill diagnosis, type of III III Condition, degree of functional limitation, or rehabilitation potential. Deductible means the amount of charges, up to the Allowed Amount, for Covered Services that are your responsibility. The term, Deductible, does not include any amounts you are responsible for in excess of the Allowed Amount, or any Comsurance/Copay amounts, if applicable. Detoxification means a process whereby an alcohol or drug intoxicated, or alcohol or drug dependent, individual is assisted through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent determined by a licensed Physician or Psychologist, while keeping the physiological risk to the individual at a minimum. Diabetes Educator means a person who Is properly certified pursuant to Florida law, or a similar applicable law of another state, to VW FIcim4�r-*-44-.4"1;ko-&y4K4i�3.—*-M&Ae�NOR�owj training and educational services. certified by the Centers for Medicare and Medicaid Services (CMMS) and the Florida &Aomcl services and support. Dietitian means a person who is property licensed pursuant to Florida law or a similar applicable law of another state to provide management services. furnished by a supplieII r or a Home Health Agency that: 1) can withstand repeated use, 2) Is primarily and customarily used to serve a medical purpose; 3) not for comfort or convenience; 4) generally Is not useful to an individual In the absence of a Condition; and appropriate for use in the home. person or entity that is properly licensed, if applicable, under Florida law (or a similar F ilialysis supplies in the patient's home under a Physician's prescription. Definitons 23-5 further described In the Trimilment and Effective Date of Coverage" section of this Benefit Booklet. Eligible Dependent means an Individual who requirements described In the Eligibility Requirements for Dependenbs) subsection of Booklet, and is eligible to enroll as a Covered Dependent. Eligible Employee means an active employee or retiree who meets and continues to meet all of the eligibility requirements described in the Eligibility Requirements for Covered Plan Participant subsection of the Eligibility for Coverage section in the Benefit Booklet and is eligible to enroll as a Covered Plan Participant. Any individual who is an Eligible Employee is not a Covered Plan Participant until such individual has actually enrolled with, and been accepted for coverage as a Covered Plan Participant by Monroe County BOCC, Emergency Medical Condition means a medical or psychiatric Condition or an injury manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (I), di), or (III) of i 4i N I I f Emergency Services means, with respect to an Emergency Medical Condition: 1 . a medical screening examination (as required under Section 1867 of the Social Security Act) that is within the capability of the emergency department of a Hospital, including ancillary Services routinely available to the emergency department to evaluate such Emergency Medical Condition; and 2. within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatme as are required under Section 1867 of an Act to Stabilize the patient. I Group Health Plan or this Booklet, -T if earlier, the first day of the Waiting Period of such enrollment. Enrollment Forms means those forms, Experimental or Investigational means any evaluation, treatment, therapy, or device which procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, or chemical compounds if, as determined solely by SCBSF: such evaluation, treatment, therapy, or approval of the United States Food and Drug Administration or the Florida Department of Health and approval for marketina has not, in fact- been given at the time such is furnished to you; or Z such evaluation, treatment, therapy, or device is provided pursuant to a written protocol which describes as among its objectives the following: determinations of safety, efficacy, or efficacy in comparison to the standard evaluation, treatment, therapy. or device; or 3. such evaluation, treatment, therapy, or device Is delivered or should be delivered subject to the approval and supervision of an institutional review board or other entity as required and defined by federal regulations; or Definigons 23-6 4. credible scientific evidence shows that such evaluation, treatment, therapy, or device is the subject of an ongoing Phase I or 11 clinical investigation, or the experimental or research arm of a Phase III clinical investigation, or ender study to determine: maximum tolerated dosagets), toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; or 5. credible scientific evidence shows that the consensus of opinion among experts is that further studies, research, or clinical investigations are necessary to determine; maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; or 6. credible scientific evidence shows that such evaluation, treatment, therapy, or device has not been proven safe and effective for treatment of the Condition in question, as evidenced In the most recently published Medical Literature In the !united Mates, Canada, or Great Britain, using generally accepted scientific, medical„ or public health methodologies or statistical practices; or i. there Is no consensus among practicing Physicians that the treatment, therapy, or device is safe and effective for the Condition HEMEEM & such evaluation, treatment, therapy, or device is not the standard treatment, therapy, or device utilized by practicing Physicians in treating other patients with the same or similar Condition. re to eviaence mean determined by BCBSF): `i. records maintained by Physicians or Hospitals rendering care or treatment to you or other patients with the same or similar Condition; reports,2. _... in authoritative medical and scientific literatun; published in the United Canada, .: Great Britain; 3. published reports, articles, or other literature of : States Department and Human Services or the r# States Public- :/ any of the National - of Health, States Office of Technology Assessment-, 4. the written protocol or protocols relied upon by or the substantiallyprotocols of another Physician or institution studying : therapy,or device; Informed5. the written -: by the treating Physician or institution or by another institutionPhysician or ■ substantially the same evaluation, treatment, therapy, or ■ or board6. the records (including any reports) of any institutional review of .: which- ■ the evaluation, treatment,or device for the Note: Administration. Definifi s 23-7 ......... ... 9714E. x ... . ... .. . Rehabilitative Services in compliance with Florida Statutes or by a similar regulatory state's applicable laws. Mew= the direct transfer of a mixture of sperm and care provider. Fertilization takes place inside like tube. Generally Accepted Standards of Medical Practice means standards that are based on credible scientific evidence published in pear- 0 by the relevant medical community, Physician Specialty Society recommendations, and the areas and any other relevant factors. Gestational Surrogate means a woman, regardless of age, who contracts, orally or in writing, to become pregnant by means of of an egg from her body. Gestational Surrogacy Contract or Arrangement means an oral or written agreement, regardless of the state or jurisdiction where executed, between the Gestational Surrogate and the intended parent or parents. Group means the employer, labor union, trust, association, partnership, or corporation, or eniltv throunh I which you and your Covered Dependents Covered Services described herein. Group Health Plan or liaGroup Plan means the plan established and maintained by Monroe County BOCC for the provision of health care under this Benefit Booklet. Health Care Services or Services includes treatments, therapies, devices, procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, chemical compounds, and direction of, Providers. Home Health Agency means a properly W. applicable law of another state, Home Health Care or Home Health Care Services means Physician -directed personal care Services provided on an pe r 0 n .a' -'re Be 6 or v d **w a 4"4 se 1 d 0 a a a n rv� an intemniftent or part-time basis directly by (or I Agency in sea of IN a ty ndirectly through a Home Health ] 1 Agencyin a denc . For pur your home or residence. For purposes of thl definition, a Hospital, Skilled Nursing Facility, nursing home or other facility will not be considered an individual's home or residenc Hospice means a public agency or private of Florida under applicable law, or a similar applicable law of another state, to provide hospice services. In addition, such licensed pain relief, symptom management, and their families, Hospital means a facility property licensed or a similar am- -.11cable law of anot"... ate_tda5: offers services which are more intensive than those required for room, board, personal services and general nursing care; offers regularly makes available at least clinical laboratory services, diagnostic x-ray services amil swgery-or sk5iabical care or other definitive medical treatment of similar extent. Definidons 23-8 The term Hospital does o:include: Ambulatory� III �f Facility; Nursing a stand-alone. J III � III M 491*�III I II II III Birthing a convalescent, rest or nursing home; or a primarilyfacility which # educational, Rehabilitative i Note.x for the treatmen disability are provided IIIIIII ilil si IIlicensed I it ii Mil III Hospital II which il+lliil t . ithe American Osteopathic Association, or the Commission dill Rehabilitativeit 4Ili payment ull MII i l services . fi be denied solely because �i and Is primarily of a rehabilitative nature. Recognition of these facilities does not expand the scope of Covered Services. It only expandssetting where Covered Services can be perfortned for coverage purposes. Identification (ID) Cardmeans _ card(s) underissued to Covered Plan Patcipants individualBlueOptions Group Health Plan. The card is not transferable to another person. Possession of : # # i' for, or covered under, BenefitBooklet. #. IndependentClinical III III III III means 483 of d or applicable examinations are performed on materials or specimens takenfrom 3.. body provide information or materials used in the diagnosis, or of .. Condition. Independent Diagnostic Testing Facility - _ ■ - is i ... E �,: #1 office, _ d practitionermobile entity, or an individual non-Physicia I performed by a licensed Physician licensed, certified non -Physician personnel appropriate peon: appropriately registered with the Agency for Health Care Administration and must comply with all applicable o.. laws of the State in which it operates. Further, such an entity must meet BCBSFs criteria for eligibility a.: an IndependentDiagnostic g Facility. Schedule of Benefits under the heading "in- E .d 4 referexceto ... Provider,-.M tine Cove rv' s a a C, i ii, I I *v be # I In -Network Provider Provider 1l..!d renderedwere you, ■contract :W ' E- to participate in E Yd S y. lue and included panelproviders (Pleasedesignated by BCBSF as "in -Network" for your Decific clan. to '..1 Sc.a# w.or Benefils). For payment purposes ProviderBenefit Booklet only, the term In -Network also refers, .. applicable, .. ... ny Florida who or which, at the time Health Care Services ; rendered under Blue X Cross Blue Shield Association's BlusCardProgram. which an egg and sperrin are combined in a laboratory dish to facilitate fertilization. If the woman's uterus. practiceLicensed Practical Nurse means a person properly licensed to practical nursing 0efrtiti S 23-9 Massage Therapist means a person properly licensed to practice Massage, pursuant to Chapter 480 of the Florida Statutes, or a similar applicable law of another state. Massage or Massage Therapy means the manipulation of superficial tissues of the human body using the hand, foot, arm, or elbow. For purposes of this Benefit Booklet, the to Massage or Massage Therapy does not include the application or use of the following or similar techniques or items for the purpose of aiding In the manipulation of superficial tissues: hot or cold packs; hydrotherapy, colonic irrigation; thermal therapy; chemical or herbal preparations; paraffin baths; infrared light; ultraviolet light; Hubbard tank; or contrast baths. the breast for Medically Necessary reasons as determined by a Physician, Medical Literature means scientific studies published in a United States peer -reviewed national professional journal. Medical Pharmacy means Physician - administered Prescription Drugs which are rendered in a Physician's office. Medically Necessary or Medical Necessity means that, with respect to a Health Care Service, a Physician, exercising prudent clinical judgment, provided the Health Care Service to you for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that the Health Care Service was: in accordance with Generally Accepted Standards of Medical Practice-, clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your illness, injury or disease; and 3. not primarily for your convenience, or that of your Physician or other health care Provider, and not more costly than an alternative likely to produce equivalent therapeutic is diagnostic results as to the diagnosis or �stx treatment of your illness. Mote: It is Important to remember that any review of Medical Necessity by us Is solely for Ote �urpr-%%e oU*tewtAJ?Q% �cccerzg% tr kamfits— under this Booklet and not for the purpose of recommending or providing medical care. In thns, rvap� w4wn2gw-Qu, itio sitec'fic Information pertaining to you. Any such review, however, is strictly for the purpose of determining, among other things, whether a Service provided or proposed meets the &- determined by us. In applying the definition of Medical Necessity in this Booklet, we may apply our coverage and payment guidelines then in effect. You are free to obtain a Service even if we deny coverage because the Service is not Medicare means the federal health insurance Act and all amendments thereto, Medication Guide for the purpose of this issued by us where you may find information bout SD cialtv AM a Note: The Medication Guide is subject to ch-u-ngiuAw any Ymn--P4-ff am Wer A ou*-meksbe at myDy-floddgbIye.!;pM for the most current guide or you may call the customer service phone number on your Identification Card for current information. Mental Health Professional means a person properly licensed to provide mental health Serv* ursuant to Chanter 491 of the Rad . Statutes, or a similar applicable law of another state. This professional may be a clinical social DeRnitions 23-ID worker, mental health counselor or marriage and family therapist. A Mental Health Professional does not include members of any religious denomination who provide counseling services. Mental and Nervous Disorder means any "8016 International Classification of Diseases, Ninth equivalents in the most recently published version of the American Psychiatric Association's Diagnostic and Statistical Manual cause, or effect, of the disorder, Midwife means a person properly licensed to practice midwifery pursuant to Chapter 467 of of another state. us means, or r Fau by BCBSF which Is available to individuals covered under this Benefit Booklet. Please note that BCBSF's Preferred Patient Care (PPC) preferred provider network is not available to individuals covered under this Benefit Booklet. Occupational Therapist means a person properly licensed to practice Occupational Therapy pursuant to Chapter 468 of the Florida Statutes, or a similar applicable law of another SIO& Occupational Therapy means a treatment that follows an illness or injury and is designed to help a patient learn to use a newly restored or previously impaired function. U, body part or restrict or eliminate body movement, Out -of pletwork meaner when used in reference to Covered Services, the level of benefits payable to an Out-of-pletwork Provider as designated on the Schedule of Benefits under the heading "Out-of-bletwork". Otherwise, Out - Provider, that, at the time Covered Services are rendered, the Provider is not an In -Network Provider under the terms of this Booklet. Out -of -Network Provider means a Provider who, at the time Health Care Services were rendered: 1 . did not have a contract with us to participate in NetworkBlue but was participating In our Traditional Program; or 2. did not have a contract with a Host Blue to participate in its local FPO Program for purposes of the BlueCard (Out -of -State) PPO Program but was participating, for purposes of the BlueCard (Out -of -State) Program, as a BlueCard (Out -of -State) Traditional Program Provider; or did have a contract to participate In NetworkBlue but was not included in the panel of Providers designated by us to be In -Network for your Plan, or 4did not have a contract with us to participate in Network8lue or our Traditional Program; or 5, did not have a contract with a Host Blue to participate for purposes of the BlueCard (Out -of -State) Program as a BlueCard (Out - of State) Traditional Program Provider. Outpatient Rehabilitation Facility means an licensed pursuant to Florida law or the similar therapy; outpatient speech therapy; outpatient occupational therapy; outpatient cardiac rehabilitation therapy; and outpatient Massage 42116s ,.�`A a bodily function impaired or eliminated by a Condition. Further, such an entity must meet BCBSF's criteria for eligibility as an Outpatient Rehabilitation Facility. The term Outpatient Rehabilitation Facility, as used herein, shall not include any Hospital including a general acute care Hospital, or any separately organized unit of a Hospital, which provides comprehensive corm flons 23-11 medical rehabilitation Inpatient services, or rehabilitation outiattent services 1 1666" nor OWED to, a UMM in specialty renaulinaLlon hospital" described In Chapter 59A, Florida 0 Pain Management includes, but is not limited to, Services for pain assessment, medication, physical therapy, biofeedback, and/or counseling. Pain rehabilitation programs are programs featuring multidisciplinary Services directed toward helping those with chronic pain to reduce or limit their pain. Partial Hospitalization means treatment in which an individual receives at least seven hours of institutional care during a portion of a 24-hour period and returns home or leaves the treatment facility during any period in which treatment is not scheduled. A Hospital shall not be considered a "home" for purposes of this definition. Physical Therapy means the treatment of disease or Injury by physical or mechanical means as defined in Chapter 486 of the Florida Statutes or a similar applicable law of another state. Such therapy may include traction, active or passive exercises, or heat therapy. Physical Therapist means a person properly licensed ts practice Physical Therapy pursuant to Chapter 486 of the Florida Statutes, or a similar applicable law of another state. ■ licensed by the state of Florida, or a similar applicable law of another state, as a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.). Physician Assistant means a person properly licensed pursuant to Chapter 458 of the Florida Physician Specialty .:E. means a United diplomates certified by a board recognized by the American Board of Medical Specialties. benefits, or payment for a Service actually provided to you (not just proposed or recommended) that is received by us an a property completed claim form or electronic "AAWAM provisions of this section. Pro -Service Claim means any request or apX1fcW*n for ur;9wa9a-urban6flN fur-a-Serviva that has not yet been provided to you and with RIME part) on approval by us of coverage or benefits for the Service before you receive it. A Pre- SeQ.2-ce CLW-v_mak�Lha a Ckmiiiv WmNing Uw,&M Care. As defined herein, a Pre -Service Claim shall not include a request for a decision or opinion by us regarding coverage, benefits, or payment for a Service dTat rendered to you if the terms of the Benefit Booklet do not require (or condition payment the Service before it is received. Prescription Drug means any medicinal substance, remedy.�, biological product, E..ug, pharmaceutical or chemical compound following statement or similar statement on the label: "Caution: Federal law prohibits dispensing without a Prescription". Prior/Concurrent Coverage Affidavit means the form that an Eligible Employee or Eligible 25a,verhie* cansw1sm4*,-i*,-SCV0F�i-s-o1` sf ft amount of time the Eligible Employee was covered under Creditable Coverage. DefinWons 23-12 that is properly licensed, if applicable, under Florida law, or a similar applicable law of another state, to provide services consisting of the design and fabrication of medical devices such as braces, splints, and arcial limbs prescribed by a Physician. Prosthetic Device means a device which body organ or replaces all or part of the functions of a permanently inoperative or malfunctioning body part or organ, 01"i V1 PCA Y1 I M IL Wy Booklet. Psychiatric Facility means a facility properly licensed under Florida law, or a similar "F'4244_11W care and treatment of Mental and Nervous Disorders. For purposes of this Booklet, a Psychiatric Facility is not a Hospital or a Substance Abuse Facility, as defined herein. law of another state. Registered Nurse means a person property licensed to practice professional nursing pursuant to Chapter 464 of the Florida Statutes, or a similar applicable law of another state. Registered Nurse First Assistant (RNFA) means a person property licensed to perform surgical first assisting services pursuant to Chapter 464 of the Florida Statutes or a similar applicable law of another state. purpose of restorin function lost due to illness injury or surgical procedures including but not limited to cardiac rehabilitation, pulmonary rehabilitation, Occupational Therapy, Speech Therapy, Physical Therapy and Massage Therapy. 077� primary purpose of which Is to restore or improve bodily or mental functions impaired or eliminated by a Condition, and include, but are not limited to, Physical Therapy, Speech Tkerp�,y, P;,I& Wa�I;y�new--t Fulix*x-ary tk-Qr2iiry or Cardiac Therapy. Self -Administered Prescription Drug means an FDA -approved Prescription Drug that you part there which meats BCBSF's criteria for WE .61IMM, state of Florida or a similar applicable law of another state, and 2) Is accredited as a Skilled Nursing Facility by the Joint Commission on Accreditation of Healthcare Organizations or recognized as a Skilled Nursing Facility by the United States under Medicare, unless such accreditation or recognition requirement has been waived by BCBSF. Sound Natural Teeth means teeth that are whole or properly restored (restoration with a,"Agqms,mi,,� *r_�4,6;cjte� tmlp�" are w!tls,� im-.*��Wierioslontal, or other conditions: and are not in need of Services provided for any reason other than an Accidental Dental Injury. Teeth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated with endodontics, are not Sound Natural Teeth. Specialty Drug means an FDA -approved Prescription Drug that has been designated, S is res as c 'a r I 1p ty lio handling, storage, training, distribution requirements and/or management of therapy. _i5 w or self.adm sp r a let sym Deli nigons Z3•Q Agreement with us to provide specific Prescription Drug products, as determined by us. In -Network Specialty Pharmacies are listed in thi inn (1.11kip organizations as designated under the Blue Traditional Program Providers means, or Speech Therapy means the treatment of refers to, those health care Providers who are speech and language disorders by a Speech Therapist including language assessment and language restorative therapy services. Stabilize shall have the same meaning with regard to Emergency Services as the to Is defined in Section 1867 of the Social Security Act. Speech Therapist means a person properly applicable taw of another state. Standard Reference Compendium means: 1) the United States Pharmacopoeia Drug Information; 2) the American Medical Association Drug Evaluation; or 3) the American Hospital Formulary Service Hospital Drug lnfannafion, Substance Abuse Facility means a facility poptr�y hm"eAimdaij. Fk#ah�wwiwtxo4W2j applicable law of another state, to provide necessary care and treatment for Substance Dependency. For the purposes of this Booklet a Substance Abuse Facility Is not a Hospital or a Psychiatric Facility, as defined herein. Substance Dependency means a Condition where a person's alcohol or drug use injures his or her health; interferes with his or her social or economic functioning; or causes the individual to Rase self-control. Traditional Program means, or refers to, BCBSF's provider contracting programs called Payment for Physician Services (PPS) and Payment for Hospital Services (PHS). For purposes of this Benefit Booklet, the to Traditional Program also refers, when applicable, to the traditional Provider contracting programs of other Blue Cross and/or Blue Shield the time you received Services from them wler m For If 1 0 ,7 participating in the Traditional Program. For purposes of payment under this Benefit Bookie only, the term Traditional Program Provider als refers, when applicable, to any health care or which, at the time Health Care Services we w r rendered to you, participated as a BlueCardl Traditional Provider under the Blue Cross and I Blue Shield Association's BlueCard Program. Traditional providers are considered out of network for benefit calculation purposes; however, does not balance bill the member. Urgent Care Center means a facility properly licensed that: 1) is available to provide Services to patients at least 60 hours per week with at least twenty-five (25) of those available hours after 5:00 p.m. on weekdays or on Saturday or Sunday; 2) posts instructions for individuals seeking Health Care Services, in a conspicuous public place, as to where to obtain such Services when the Urgent Care Center is closed; 3) employs or contracts with at least one or more Board Certified or Board Eligible Physicians and Registered Nurses (RNs) who are physically present during all hours of operation, Physicians, RNs, and other medical professional staff must have appropriate training and skills for the care of adults and children; and 4) maintains and operates basic diagnostic radiology and laboratory equipment in compliance with applicable state and/or federal laws and regulations. For purposes of this Benefit Booklet, an Urgent Care Center is not a Hospital, Psychiatric Facility, Substance Abuse Facility, Skilled Definigans 23-14 Waiting Period means the length of time established by Monroe County BOCC which must be met by an individual before that this Benefit BookIeL Zygote Intrafallopian Transfer (ZIFT) means a process in which an egg is fertilized in the to the fallopian tube at the pronuclear stage (before cell division takes place). The eggs are retrieved and ferzed on one day and the zygote is transferred the following day. Definitions �-15 Qualified Medical Child Support Orders - The Plan will provide benefits as required by any Qualified Medical Child Support Order (MCSO). A MCSO can be either: 1) A Qualified w,»�«=�©: Child Support Order (MCSO) that satisfies the requirements of Section 009(s) of ERISA; or 2) A National Upon receipt of a MCSO or NMSN by a Covered Employee/Rebree notification must be given to the Monroe County Group Health Plan Administrator (Benefits Office) within 31 days of receThe Covered Employee/Retiree will need to provide any reasonable information or assistance to the Monroe County Group Health Plan Administrator (Benefits Office) in connection with the MCSO. BlueOptions Schedule of Benefits — Plan 03559 Important things to keep In mind as you review this Schedule of Benefits: • This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your benefits can be found. • Networlialue is the panel of Providers designated as In -Network for your plan. You should always verify a Provider's participation status prior to receiving Health Care Services. To verify a Provider's specialty or participation status, you may contact the local BCBSF office or access the most recent BlueOptions Provider directory on our wetwite at www.floridablue-com, If you receive Covered Services outside the state of Florida from BlueCarda participating PRO Providers, payment will be made based on In -Network benefits. * References to Deductible are abbreviated as "DED". • Your benefits accumulate toward the satisfaction of Deductibles, Out-of-pocket Maximums, and any applicable benefit maximums based on your Benefit Period unless indicated otherwise within this Schedule of Benefits. Your Benefit Period... .............................. ................. __ ....... . .. ___ ...... _ ........ __ ......... ____ 01 AN — 12/31 Benefit Description In -Network Out -of -Network Deductible (DED) Per Person per Benefit Pence $300 Per Family per Benefit Period $600 Per Admission Deductible (PAD) $150 $150 Emergency Room Per Visit Deductible (PVD) $75 $75 Coinsurance (The percentage of the Allowed Amount you 25% 55% pay for Covered Services) Out-of-pocket Maximums Per Person per Benefit Period $7,500 Per Family per Benefit Period Not Applicable the Out-of-pletwork column, unless otherwise indicated within this Schedule of Benefits. This Includes the Deductible and Out -of -Pocket Maximum amounts. � :.G � E ESP E ;. �: �E ■ 'E #' N • Non -covered charges • Any benefit penalty reductions 40 Charges in excess of the Allowed Amount • DPD • PAD or PAID, when applicable Important information affecting the amount you will pay: As you review the Cost Share amounts in the following charts, please remember: • Review this Schedule of Benefits carefully; it contains important information concerning your share of the expenses for Covered Services you receive. Amounts listed in this schedule are the Cost Share amounts you pay. • Your Cost Share amounts will vary depending upon the Provider you choose, the type of Services you receive, and the setting in which the Services are rendered. • Payment for Covered Services is based on our Allowed Amount and may be less than the amount the Provider gills for such Service, You are responsible for any charges in excess of the Allowed Amount for Out-of-plet orle Providers. • If a Copayment is listed in the charts that follow, the Copayment applies per visit. 2 Office Services A Family Physician Is a Physician whose primary specialty is, according to BCSSF's records, one of the following: Family Practice, General Practice, Internal Medicine, and Pediatrics. Benefit Description In -Network Our-ey-Network Office visits and Services not otherwise outlined in this table rendered by: Family Physicians: a) Office visit only $20 DED + 55% b) All Services other than office visit DED + 25% DED + 55% Other health care professionals licensed to perform such Services: a) Office visit only $20 DED + 55% b) All Services other than office visit DED + 25% DED + 55% Advanced Imaging Services (CT/CAT Scans, MRAs, MRN, PET Scans and DED + 25% DED + 55% nuclear cardiology) All other diagnostic Services (e.g., X-rays) DED + 25% DED + 55% Allergy Injections rendered by: Family Physicians $10 DED + 65% Other health care professionals licensed to $10 DEC + 55% perform such Services E-Visits rendered by: Family Physicians $10 DED + 55% Other health care professionals licensed to $10 DED + 55% perform such Services Durable edical Equipment, Prosthetics, and DED + 25% DED + 55% Orthotics Convenient Care Centers $20 DED + 55% Chiropractic Services Note: Includes office and free-standing facilities DED + 25% DED + 55% Preventive Health Services Benefit Description In -Network Out -of -Network Adult liveliness Services Rendered by: $0 55% Family Physicians Other health care professionals licensed to perform such Services $0 55% All other locations $0 55% Adult Well an Services Rendered by, Family Physicians $0 55% Other health care professionals licensed to perform such Services $0 55% All other locations $0 55% Child Health Supervision Services Rendered by. Family Physicians $0 55% Other health care professionals licensed to $0 55% perform such Services All other locations $0 55% Mammograms $0 $0 Routine Calonoscopy $0 $0 Outpatient Diagnostic Services Benefit Description In -Network Out -of -Network Independent Clinical Lab so RED + 55% Independent Diagnostic Testing Facility Advanced Imaging Services (CT/CAT Scans, MRAs, MRls, PET Scans and nuclear DED + 25% RED + 55% medicine) All other diagnostic Services (e.g,, X-rays) DER + 25% DED + 55% Outpatient Hospital Facility See Hospital Services Outpatient Medical Pharmacy Benefit Description In -Network Out-of-Retwork Prescription Drugs administered in the office by: Family Physicians 20% DED + 50% Physicians other than Family Physicians and 20% DED + 50% other health care professionals licensed to perform such Services Out-of-pocket Maximum per Person per Month 200 Not Applicable (applies only after DED is satisfied) Important — The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and is in addition to the office Services Cost Share. Immunizations, allergy injections as well as Services covered through a pharmacy program are not considered Medical Pharmacy. Please refer to your Benefit Booklet for a description of Medical Pharmacy. Benefit Description In-oar4, I Out-ol-Network Ambulance Services OF + % Emergency Room Visits See Hospital Services Emergency Room Visits Urgent Care Center a) Office visit only 20 OPO + 5% } All Services other than office visit OFO + 25% OFO + 55% Benefit Description r Out -of -Network Ambulatory Surgical Center Facility (per visit) CEO + 25% OCO + 55% Radiologists, Anesthesiologists, and DSO + 25% OSO + 25% Pathologists Other health care professional Services OPO + 25% DEC + 55%rendered by all other Providers Outpatient Hospital Facility See Hospital 1 es Outpatient ii �...,. Ire -Network Option 1* Option 2* Out -of -Network and BenefltDescriptionand Out -of -State Traditional Blue ard`� Providers f�articipatin Inpatient 150 PAD +CPC) + Facility Services ( per admission) 15C1 P�� + �ECI �/� 55% Physician and other health carp professional Services DEC + 25% �EI� + 51 Outpatient Facility (per visit) DECK + 5% RED + 55% Physician and other health care professional Services DEE + 25% DPD + 25% Therapy Services E + 2 % DEC) + 55% Emergency Room Visits 75 PV + DEC + Facility 75 PAD + DER + 25% 251% Physician and other health care DEC + 25"% CC) + 25g1 professional Services Irrroortant° Certain categories of Providers may not be available In -Network In all geographic regions, This includes, but . to, anesthesiologists,radiologists,is and emergency room physicians. We will pay for Covered Services rendered by a Physician in a Hospital setting (i.e., inpatient, outpatient, or emergency room) at the In -Network benefit level. If such Covered Services were rendered by a Physician who is not In -Network, or a Physician who is not participatingour ■ responsible for the difference between what we pay and the Physician's charge. Claims paid in accordance with this note will be applied to the I n-Network DER and Out-of-pocket Maximums. *Please refer to the current Provider Directory to determine the applicable option for each In -Network Hospital Behavioral Health Services Benefit Description In -Network Out- ot-Network, Mental Health and Substance Dependency Care and Treatment Services Outpatient Facility Services rendered at; Emergency Room $75 PVD + DED + 25% $75 PVD + RED + 25% Hospital DER + 25% DED + 55% Physician Services at Hospital and ER DER + 25% DED + 25% Physician and other health care professionals licensed to perform such Services Family Physician office: a) Office visit only $20 DED + 55% b) All Services other than office visit DED + 25% DER + 55% Specialist office: a) Office visit only $20 HER + 55% b) All Services other then office visit DED + 25% DED + 55% All other locations DED + 25% NED + 55% Inpatient Facility Services $150 PAD + DER + 25% $150 PAD + DED + 55% Physician and other health care professionals DER + 25% DER + 25% licensed to perform such Services ONW:Na RIMMM Ambulance Services Per day for ground, air and water travel .... . ..... ........ ...... ......... . . . - — — . - . - $ 5,500 Note: In addition to the Cost Share listed in this Schedule of Benefits you are responsible for any additional amounts that exceed the per day maximum. Enteral Formula per Benefit Period. . . .... — .... ....... ---- ......... -- .................... ................ $2,500 Home Health Care Visits per Benefit Period ... --- ................... — ..................................... — ....................... 40 Inpatient Rehabilitation days per Benefit Period ............................ ........................................ ............... 21 Outpatient Therapies and Spinal Manipulations Visits per Benefit Period..... ........ -- ......... -- .. . ...... ,50 Note: Note: Spinal Manipulations are limited to 26 visits per Benefit Period and accumulate towards the Outpatient Therapies and Spinal Manipulations benefit maximum. Refer to the Benefit Booklet for reimbursement guidelines. Preventive Adult Afellness per Benefit Period ... ........ ........ Unlimited Skilled Nursing Facility days per Benefit Period . ..... ---- ... -- .......... — ............ ......................... Unlimited Total Lifetime Maximum Benefft ........ ............ ....... — ......... --- ................. Unlimited Additional Benefits/Features Benefit Maximum Carryover . . . . . . . . . . . . . . to your Benefit Period maximums under the prior BCBSF or Health Options, Inc. policy will be applied toward your Benefit Period maximums under this plan. Supplement to the BlueOptions Benefit Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan Effective as of January 1, 2013 T1117 is a supp,M&Mai M �4� Benent zoo el k--tmOKIeI) an is imen Is 0 rovi a information not otherwise included in the Booklet. In the event of a conflict between this Supplement and the Booklet, the provisions of this Supplement shall govern, In the event of a DEFINITIONS `—~~''~~^'~~^'~~~~~'`~~~~... ^~~~~`~^~~'... 3 Eligible Domestic ..................... .......... ........ 3 Eligible Retiree .... ...~...~..~~........ .-~........ .~..._.~~........ -~.~~~~.~~..~....6 ELIGIBILITY FOR COVERAGE - RETIREES AND DOMESTIC PARTNERS ... .... ........7 EligibleRetirees. ... ................................ ..^...................................................... ...... .7 Domestic....... ......^^-^..^.^.^.....~.~......^..... .,.................................... ...7 PRESCRIPTION C0VEBAGE........ ........................ ..,......... .,.......,........,......... ....7 OPTOUT.. .... .~..~..~~..~.....~.~.~......~......... ........ ____ ......... .~.~..~....~~.~..8 Initial Enrollment Period ..... ......... .-....-....~................... ..,....... ...^,....... ............ ....................... 8 Open Enrollment Period .,...~..................................._...,_._..,............. ........ .....8 CESSATION QF ACTIVE W0RK.,............................ .-........_.-._-........~..~...~...8 ApprovedMedical Leave .... ..-.......... ...._..........,..,.......~.......... ....-......... ........ 0 Rehire/Reinstatement ''—`—^^~--~^—`^^~''~~~^^`^^'^^^^'~^'~'~^'~^^~^~~^'~^~~^~~'~ ActiveMilitary Duty.. ....... ................ ..~..... ....................................... .....~..~........ .....9 CONTINUATION OF COVERAGE ......____ ...... ____ ............. ......... ........ ......... ... .... ... g Surviving Spouses of Covered Retirees ... .................... ............. ...... -.................. .................... g DomesticPartners ....... ....... ......... ........ ............... .-.... ................ ............. ...................... _9 General Notice of COBRA Continuation Coverage Fights .^............. ..-......................9 What is COBRA Continuation .......... ..._..... .... ..... ..... ........ ..,......,........,l0 PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHDLD8EN`SBEALTB INSURANCE PROGRAM (Cf£0P)..................... ...... ..... .... .,~,.,,.~.,........ ..... ~....... .......l3 lb 4U Ulu flUIL ILIUMb V1 r$,VbU1UL1U1L No. 081-1998 as restated below: A. Domestic Partners. "Domestic Partners" are two adults who have chosen to share one another's lives in a committed family relationship of mutual caring, Two individuals are considered to be Domestic Partners if. I . they consider themselves to be members of each others immediate family; 2. they agree to be jointly responsible for each other's basic living expenses; 3. neither of them is married or a member of another Domestic Partnership; 4. they are not blood related in a way that would prevent them from being married to each other under the laws of Florida; 5. each is at least of the legal age and competency required by Florida law to enter into a marriage or other binding contract; 6. they must each sign a Declaration of Domestic Partnership as provided for in Section 14.03 of Monroe County BOCC's Personnel Policies and Procedures Manual; 7. they both reside at the same addres& B. Joint Responsibility for Basic Living Expenses, "Basic living expenses" means basic food and shelter. "Joint responsibility" means that each partner agrees to provide for the other's basic living expenses while the domestic partnership is in effect if the partner is unable to provide for him or herself. It does not mean that the partners must contribute equally or jointly to basic living expenses. C. Competent to Contract. "Competent to Con tract"means the two partners are mentally competent to contract. D. Domestic PartnersJup. "Domestic Partnership" means the entity formed by two individuals who have met the criteria listed above and file a Declaration of Domestic Partnership as described below. E. Declaration of Domestic Partnership. "Declaration of Domestic Partnership" or "DDP" is a form provided by the Human Resources Director. By signing it, two people swear under penalty of perjury that they meet the requirements of the definition of domestic partnership when they sign the statement. The form shall require each partner to provide a mailing address. F. Dependent. "Dependent" means an individual who lives within the household of a domestic partnership and is: 1. A biological child or adopted child of a domestic partner; or 2. A dependent as defined under County employee benefit plan document. 3 A ward of a domestic partner as determined in a guardianship proceeding. Employee means an employee of the Board of County Commissioners, the constitutional officers or the Mosquito Control Board, except where the context is otherwise. A. An employee and his/her domestic partner as set out in Section 14.02 are eligib to declare a Declaration of Domestic Partnership (hereafter DPP) in the presenc of the Human Resources Director, or I te employee partner may present a signe and notarized DDP to the Human Resources Director. The DDP shall include t name and date of birth of each of the domestic partners, the address of their common household, and the names and dates of birth of any dependents of the domestic partnership, and shall be signed, under the pain and penalties of ped by both domestic partners and witnessed (two) and notarized. h B. As further evidence of two individuals being involved in a domestic partnership, two of the following documents must be presented along with the DDP to the Human Resources Director - I , A lease, deed or mortgage indicating that both parties are joint responsible; I Driver's licenses for both partners showing same address; I Passports for both partners showing the same address; 4. Verification of a joint bank account (savings or checking) 5. Credit cards with the same account numbers in both names; 6. Joint wills; 7. Powers of attorney; or S. Joint title indicating both partners own a vehicle. C. An individual cannot become a member of a domestic partnership until at least six months after any other domestic partnership of which she or he was a member has ended and a notice that the partnership has ended was given as provided for in Section 14.04. This does not apply if their domestic partners are deceased. D. Domestic partners may amend the DDP to add or delete dependents or change the househoE.. address. Amendments to the DDP shall be executed in the same manner as the declaration of a domestic partnership. 10=0 WRIN A. A domestic partnership is terminated when: 1. one of the partners dies; 1one of the partners marries; or 3. a domestic partner files a termination statement with the Human Resources Director. A domestic partnership may be terminated by a domestic partner who files with the Human Resources Director by hand or by certified C 11 IS !!1 1111111 ill . . . . . . . . . . . . . . . mit I a Itm J. 251119 ....'s. ...W. .3 ..' U -.21110L. W srlmn�M 61 IL4;;l 142 MW U101V FV lb ati J�; IS eble to apply for coverage under this Booklet: of their official retirement under the Florida Retirement System (FRS) and if not currently an Eligible Employee, that Monroe County was their last FRS employer prior to retirement. If the Eligible Retiree fails to elect retiree coverage at time of retirement, waives retiree coverage or lets coverage lapse, the Eligible Retiree will permanently lose entitlement to enroll under the Monroe County Group Health Plan, 30 day Retail Generic (Tier 1) $ 10 Formulary Brand (Tier2) $25 Non -Formulary Brand (Tier 3) $70 90 Day Retail Generic (Tier 1) $25 Formulary Brand (Tier2) $62.50 Non -Formulary Brand (Tier 3$175 90 Day Mail Order Generic (Tier 1) $25 Formulary Brand (Tier2) $62.50 Non -Formulary Brand (Tier 3) $175 Health Ian unless you have a Special Enrollment right or during a future Open Enrollment Period. Open Enrollment Period means the period selected by Monroe County during which you can elect coverage for yourself and/or your eligible dependents, or Opt Out of coverage, for the immediately following Plan Year. You can Opt Out by indicating that you elect to waive coverage on the Monroe County Benefits Enrollment Form. If you Opt Out during the Open Enrollment Period, you will not be able to enroll in the Monroe County Group Health Plan unless you have a Special Enrollment right or during a future Open Enrollment Period, CESSATION OF ACTIVE WORK Approved Medical Leave If an Eligible Employee ceases Active Work due to illness, injury or pregnancy their Employer in its sole discretion may approve a medical leave of absence. Coverage for the Eligible Employee will continue under the Plan, but for no longer than six (6) months from the date the approved medical leave begins, Coverage of Eligible Dependents will continue during this time provided required premiums are continued to be paid. Notification of all approved medical leave must be provided to the Monroe County Group Health Administrator (Benefits Office) by the Employer. The notification should contain the date of when the leave began and when it will end. An Eligible Employee who has been on an approved medical leave must return to active work for a minimum of 30 days after the approved medical leave ends. In the event an Eligible Employee on an approved medical leave does not return to active work at the end of the leave, the Eligible Employee will be required to reimburse the Plan for the health benefit premiums paid during the leave to continue coverage. Note: When an Eligible Employee fails to return to active work because of the continuation, recurrence, or onset of either a serious health condition of the Eligible Employee or an Eligible Rehire/ Reinstatement OR wo for Coverage section. However, the Plan allows a grace period of 2 days following the date of a f coverave donne w ic aT----- E . ible R-jaw.-Iovee mav be rehired or reinstated without low %VLUALL V111 OULIVU 1111 Y L)y a L.AL?$LtYlko L.Allp Z!71 1V11rVL rehired or reinstated will be treated as if the Eligible Employee were on an approved leave of absence for purposes of eligibility under the Plan. The Plan's waiting period or preexisting condition exclusion period will not be applicable. CONTINUATION OF COVERAGE Surviving Spouses of Covered Retirees: Upon the death of a Covered Retiree, the Surviving Spouse may continue coverage under the Monme County Group Health Plan provided: (1) they do not remarry; () they may timely payment of any required contribution, It is the sole responsibility of the Surviving Spouse to notify the Monroe County Group Health Plan Administrator (Employee Benefits Office) of a change in their marital status. Domestic Partners: For purposes of COBRA Continuation Coverage Rights, a Domestic Partner of an Eligible Employee shall be treated as the Eligible Employee's "spouse" and the dependent child(ren) of a Domestic Partner shall be treated as the Eligible Employee's stepchild(ren). General Notice of COBRA Continuation Coverage Rights You are receiving this notice because you are or have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA --ontinuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan's Benefit Booklet or contact the County's Employee Benefits Department. What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: • Your spouse dies; • Your spouse's hours of employment are reduced; • Your spouse's employment ends for any reason other than his or her gross misconduct, • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: • The parent -employee dies; • The parent -employee's hours of employment are reduced; • The parent -employee's employment ends for any reason other than his or her gross misconduct; • The parent -employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage tinder the plan as a "dependent child," ---------------------------------------------------------------------------------------- Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the Monroe County Board of County Commissioners, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. ---------------------------------------------------------------------------------------- The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Benefits Office has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Benefits Office of the qualifying event. You Must Give Notice of Some Qualifying Events 268, Key West, FL, 33040; fax (305) 292-4452. elect OBRA continuation coverage on behalf of their cMdrcn. IIJIU11IIIIIIIII III Jill RIMINI I lill I 111 11111111111111111! 111111 '111 Illiplilli AaRMUSEM11011 U) Do UJISIMICU ULM YUJI in a lumnely 1715 10 your entire family may be entitled to receive up to an additional I I months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have atpr�ai-. a�—s&rne time beficra the ftth-day s&Q wnl 10t it. lew.T until the end of the 18-month period of continuation coverage. Recond qualifying event e-rilension of 18-monds period of condauadon coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation covera le for a maxim NE"Metiji It ismat X-Mapt Call 1 the EBSA website at www.doLgov/ebsa, (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's wcbsite.) Keep Your Plan Informed of Address Changes In order to protect your family's rights, you should keep the County's Employee Benefits Offic. informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the County's Employee Benefits Office. You can obtain information about the Group Health Plan and COBRA from: Employee Benefits Senior Benefits Administrator 11 on Simonton Street, Suite 2-268 Key West, FL 33040 (305) 292-4448 INSURANCE PROGRAM (CHIP) 1 M.... vim 111mr- F-m"92; F If YVor alllLrZ UNly lid for coverage, These States use funds from their Medicaid or CHIP programs to help people who are eligible for these prorams, but also have access to health insurance through their empl W. oyer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. your &,*S*&ro6 are ak-epity-sm-u-Bai in Meiicaiircc CFN1r, and ycu -wAtate_liged below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. Sai out JLT-0013CRIUCIRLZ d1%1 I tAtl I al"y 0 t 1 -1 arrr.-it yvix-depertients inigat 41-e eli6bl&4r-eimlicl�of kicse-progrants, you coa enutac�-jotiffr S&a Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply, If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer -sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a "special utwIh eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askcbsi.dol.gov or by calling toll -free 1-866-444-EBSA If you live in one of the following States, you may he eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, 2012. You should contact your State for further information on eligibility — ALABAMA - Medicaid COL{ DO - Medicaid Medicaid We site: httm,-'2wwwcolarado.gov.: Website., http:.-.:www.medicaid.alabama.gov Medicaid Phone (in state): 1-800-866-3513 Phone: 1-855-692-5447 Medicaid Phone (Out of state). 1-800-221-3943 ALASMedicaid Webow http:.:t'health.hs!i.state.ak.us.:dp,,iY/program medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA - CHIP FLORIDA - Medicaid Welesite: http:/.-www,azahcces.gov.-applicants Website.- ht",2,.v,flmedicaidtpirecovery.com/ Phone (Outside of Mariclold County): 1-877-764-5437 Phone: 1-877-357-3268 Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid Website: hap. ictch.georgia.gov' Click an Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO - Medicaid and CHIP MONTANA - Medicaid Medicaid Websne: www,accesstohealtliinsurance.idaho, ov Website: http:/'-medicaidprovider.lihs.mLgov.-elientpages/ Medicaid Phone: 1-800-926-2588 clientindex.shtmi CHIP Website- Ew&Aw.mmKdicmawidJARh9x0 Phone: 1-800-694-3084 CHIP Phone- 1-800-926-2588 INDIANA - Medicaid NEBRASKA - Medicaid Websitc: hupd/vvww.in.gov/fksa Website: jCyA.ACCESSNebraqkane.gov Phone: 1-800-889-9949 Phone- 1-800-383-4278 IOWA - Medicaid NEVADA - Medicaid Website: www.dhs.state.ia.us/hipp/ Medicaid Website: III!! ��/Idwss.,ovmv.' Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900 KANSAS - Medicaid Website: http://www.kdheks.govlhcf/ Phone: 1-800-792-4884 KENTUCKY - Medicaid NEW HAMPSHIRE- Medicaid Website: http://chf,.i.ky.gov/dms/default.htm Website: Phone: 1-800-635-2570 http://www.dhhs.nh.gov.-oii/documenL-Jhippapp.pdf Phone: 603-271-5218 LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP Website: htip://www.lahipp.dhh.louisiana.gov Medicaid Website: http:.-',-www,state,nj,us/humans;� �iccs/ Phone: 1-888-695-2447 dmahs/clients/medicaid/ Medicaid Phone: 1-800-356-1561 MAINE - Medicaid CHIP Website: http:,-'.:Mlv.lw.njfamilyeare.org/index.htmi Website: http://www.maine.gov/dhh!;Iofi/public. CHIP Phone: 1-800-701-0710 assistance/index.html Phone; 1-800-977-6740 TTY 1-800-977-6741 MASSACHUSETTS -- Medicaid and CHi-P NEW YORK - Medicaid Website: http-.-'.."www.ma,;s.gov..'MassHealth Website: http:.-'.."www.nyhealth.govlhealth-care/mcii7caid/- Phone: 1-800-462-1120 Phone. 1-800-541-2831 MINNESOTA - Medicaid NORTH CAROLINA - Medicaid Website: http:,-'2'www.dhs.statc.mn.us/ Website: http.-.-.'www.ncdhhs.gov/dma Click on Health Care, then Medical Assistance Phone, 919-855-4100 Phone, 1-800-657-3629 MISSOURI -- Medicaid NORTH DAKOTA - Medicaid Webske: Websitc: http;..::'w%vw,dss.mo.gov.'mlidiparticipant4pag&hipp.him http:.-'..'www.nd.gov/dhs/service�s/medicaiscrv.:mcdicaid/ Phone. 573-751-2005 Phone: 1-800-755-2604 OKLAHOMA -Medicaid and CHIP UTAH - Medicaid and CHIP Website: http:.:.-www.insurcoklahoma.org Website: http.-i/heakh.utah.gov--upp Phone: 1-888-365-3742 Phone: 1-866-435-7414 OREGON - Medicaid and CHIP VERMONT- Medicaid Website: http.,-.:www.oregonhealthykids.gov Website: http-..".-www.geenmountaineare.org/ http:.-"www,hijossatudablesoregon.gov Phone: 1-800-250-8427 Phone: 1-877-314-5678 PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP Website: http:,'.-'www.dpw.state.pa.usihipp Medicaid Website: http-,-'.'www.dmas.virginia.gov..rc-p-- Phone: 1-800-692-7462 HIPP.larn Medicaid Phone-, 1-800-432-5924 CHIP Website: hItp:!.-'www,lArnis.oqy` CHIP Phone: 1-866-873-2647 RHODE ISLAND - Medicaid WASHINGTON - Medicaid Website: www.ohhs.ri.gov Website: hitp:,-.;hrsa.dshs.wa.gov.-'Premiumpymt/AFpiy,shtm Phone: 401-462-5300 Phone- 1-800-562-3022 ext. 15473 SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid Websitc: http:--'-'www.scdhhs,gov Welvate: www,dhhr.wv.gov.'bms/ Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Party Liability SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid Website: http..-:'dss.sd.gov Website: http:.-.:www.badgercareplus.org/pub&/p-I0095.htrn Phone: 1-888-828-0059 Phone: 1-800-362-3002 TEXAS - Medicaid WYOM ING - Medicaid Websitc, https:.-'.."%&vw.gethipptexaq,com/ Website: h4:.-..-health.wyo.gov/healthearefin/equalitycare Phone. 1-800-440-0493 Phone: 307-777-7531 To see if any more States have added a premium assistance program since July 31, 2012, or for more information on special enrollment rights, you can contact either. U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services =ALIAIZ'� www,crns.hhs_vnv 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565 Prescription Drug Benefit (administered by Envisiordys) Toll -Free Customer Service: (800) 361-4542 Website: www.envisiorox.com Vision Benefits ViAeri Serrice Nwn hisiamnee CQrnyw2y., Toll -Free Customer Service: (800) 877-7195 Website: www,vsr),com Dental Benefle; (Insured by United Concordia) Tofl-Free Customer Service: (800) 332-0366 Website: www,unitedconcordia.com Life, Accidental Death and Dismemberment, and Disability Benefits (Insured by Hartford Life and Accident Insurance Company) Toll -Free Disability Claims: (800) 303-9744 Toll -Free Life and AD Claims: (800) 563-1124 Website: wivw.theliartford.com/emploveebenefits Employee Assistance Program (Administered by Horizon Health) Toll -Free Customer Service: (800) 272-7252 (24 hours per day, 7 days per week) Website: www. 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Please be brief - If you receive an offer message you have exceeded the space alloted for your reponse. please shorten your response to fit the available space. If you cannot complete your response In the space allocated, you will have the opportunity to provide supplemental In on Incther sections of your Proposal (TAB 6). Proposer Name: r1upubul rmsdn. Proposer Telephone: How long has your a anizalian n in business? Year established: anon:Additional info Has your company dens business under ether names? If yes, ple e provide Yes: historical background wlth assoxxclatedd venders n: fines, etc) Have you ever been suspended from writing this line of coverage? Yes: If yes please describe. No: if yes, please explain: 2. Is your organization licensed to do business in all 50 states and U 7S territories? if Yes no, identify the stalesnerfitories in which you are not currently licensed. No, if no, Pease explain: 3. What percentage of the risk does your company assume? % It less than 100%, please loan* additional reinsurers) and the respective If less than 100%, please explain percentage of assumed liability. Request for Proposal Specific and Aggregate Stop Loss insurance In what month do your reinsurance treaties renew? Month: Additional Information: 4. How many excess loss clients do you currently have? 9 of Clients: Additional information How much annualized premium do these clients represent? $ Additional Information 5 Please provide your current A K Best Rating and Financial Size Category. AM Best: Financial Size CategoRn Additional Information: 6. Please describe your disclosure process for pre -sale and at renewal (if different), Pre -Sala: Renewal: Additional Information: 7. Please provide a copy of your reinsurance contract and any amendments lncluded; Yes: No: Additional Information: When was the enclosed contract adopted? Please provide a copy of your disclosure statements Included Yes: No: Additional Information 8. In most cases, we require that your organization work directly with out Consultant Agree: rather than our client's claims administrator (TPAs, BCBS plans, carriers, etc.) on Disagree: such things as: Additional Information Renewals Specific & Aggregate contract concerns Plan DocumenUSPD adoption I approval Plan amendments PROPOSAL RIESPONSSS g. What is the minimum group size for which your company will issue a proposai? Employee Lives: Additiona'.:nfiermation, What Industries (if any) does your company consider to be'preferre? Please list, 11, What industries (if any) does your company consider to bei'moligible"? Please list. 12, For public wonder, do you have any restrictions on percentages of certain types of % employees, such as police and fire employees? N/k Additional I rimmusion: i:L Is your organization able to work with any claims administrator (TPAs. DCAS plans, Yes: carriers, etc?) No: If no, provide a listing of all U S. based claims administrators with whom your If no, please explain: organization will do business Please also indicate those that may have a'preferrod' status and describe the advantage to the client in do up business with these ce ms administrators. 14. Is your orgarazation's excess loss contract guaranteed renewable? Yes: If no, describe your determination and notification methods, No: If no, please expla rt Additional I nformation: Request for Proposal Specific and Aggregate Stop Loss Insurance 15, Does your second year contract automatically renew as a paid contrad? Yes: No: If no, please explain: Additional Information: 16, Is your organization capable and willing to contact the claims administrafter (TPAs, Yes: BCBS Mans, carriers, AD,) or Case Management firm directly to obtain additional No: information related to large claimants? Additional Information; 17-, When do you consider claims experience to be fully credible? Please descrftko. Specific: Aggregate: Additional Information: TF- Coverage is based on a ma -less I no -gain full transfer of coverage basis. If -disagree, Agree: please explain. Disagree: If disagree, please explain: Additional Information: 19-, We require firm rates at least 120 days Par to a&. If disagree, please explain, Agree: Disagree: If disagree, please explain: 20, Our Consultant creditors cmemge to�ba 'Wursy Men the.mw.carder Is In receipt Agree: of 11W bluder check or flart niershe-purkrw p"I and averaged 6ppk4m Do :�6 Disagree: Amagres wiift1hkv04Wwe If disagree, please explain: ii diestereae, moah. 21, me Onccec r firm or rates are presented and coverage is bound, under which circumstances, if any, would your organization modify rates / factors mid year? 22. Are you able to propose, a terminal liability option for a group that may, at some point Yes: in the future, choose to convert to a fully4roured arrangement? No: Additional Information: What is the cast to include this option? Cost: $ 1 as I me or: additional: A Additional Information: Is this option available at initial policy issue and also at renewal? Yes: No: Additional hibernation: 121 Does a your b your organization offer 'preforredi'micing based upon the client's Yes: networkisf? No: Additional Information; I if Yes, order list, f yes, provide a listing of the networks your organization has rated; identify the status level for each and the associated percentage of savings discount Space is provided for four (4) Network& If necessary, list additional networks under Network Name I Status Level I % Of Savings 'Additional Information*, 2 3 4 Additional Information: 24. What is your range of commissions offered? Specific: Aggregate: Can you provide rates net of commission? Additional Information: Request for Proposal Specific and Aggregate Stop Loss Insurance 2& "'a" Do you require that the prospective client purchase additional lines of coverage in 0 "in require Yes: order to hire stop loss coverage with your organization? If yes, outline your ""a "so No: ants requirements, If yes, please explain: D Do you offer Do you offer pricing consideration when multiple lines of coverage are purchased? If Yes: so, please provide details. d' No: If yes, please explain: 26 Do you limit the percentage of covered lives that are COBRA and / or -retirees? If Yes: yes, please provide details. No: If yes, please explain: What is the minimum individual specific deductible your company offers? $ Additional Information: 2& What percentage discount I credit is applied to your "first year(112J12) specific moving? 29. How long are your specific rates guaranteed? ths?a? 11 11 Are you willing to guarantee these rates for a period longer than twelve months? Yes: yes, will this impact rates? If yes, how so? No: If yes, please explain- , 3 36, Please describe the specific incurred/paid contact periods (i.e., 12/12, 12112 Yes: No: 12/15, Mc,) that you offer. 12115 Yes: No: 12118 Yes: No: 15112 Yes: No: 18112 Yes: No: 24112 Yes: No: Other, Additional Information 31,_ Is there a run-in limit on specific stop less? if yes, what is one percentage or formula? Yes: No: if yes, please explain: Additional Information 32, What is the maximum individual lifetime maximum amount your contract recognizes Unlimited Yes: No: as eligible dw,, $2 million, $5 million, unlimited)? $ million per individual Additional Informabom Do you have more than one option available? Yes: No, Additional Information: 33, Confirm that your specific coverage(s) can include the following benefits: A) Yes: No: A) Medical B) Yes; No: B) Prescription Drug C) Yes: No: C) Vision D) Yes: No: 0) Dental Bit Yes: No: E) Short Term Disability Other Additional Information: 34. Do you laser individuals at policy inception? Yes: No: Additional Information: Do you laser individuals at renewal? If yes, indicate whether this, applies only to Yes: those Insured under the initial contract terms, or if potentially large claimants are 1 No: reviewed annually. If yes, Mason, explain: If you do not laser, will you laser upon request and offer a lower premium? Yes: No: Additional Information: 11� Request for Proposal Specific and Aggregate Stop Loss Insurance If you do laser, will you offer a prenturn Increaseoclead of the laser? Yes: No: Additional Information: 35. Dom yourorgarnzation offer the specific deductible on a standard, aggregating and I Standard., or family basis? Aggregation: Family: Other, Additional Information: AGGREGA7E RESPONSES What percentage discount I credit is applied to your "first yeard a,, 1121ti aggregate pricing? 17 How long is your aggregate premium guaranteed? Are you wil'ing to guarantee these rates for a Forms -onger than twelve months? If Yes: so. how would this impact rates? I No: if yes, please explain: 38. Please describe the aggregate mocred I paid contract periods (t.e., 12112. 12112 Yes: No: 12/15, etc.) that you offer. 12/15 Yes: No: 12/18 Yes: No 15112 Yes: No 18/12 Yes: No 24112 Yes: No Other. Additional Information. 39. Confinn that W.r aggregate coverage can nclude the fAlowing benefits: A) Yes: No: A) Medical B) Yes: No: B) Prescription Drug C) Yes: No: C) Volon D) Yes: No: 0) Denta-.- E) Yes: No: 5) Short Term Disability Other, Additional information: 40. At what percentage of expected claims can the aggregate corridor be set? 110%; 115%� 120% 125W Other. Can you quote more than one option? Yes: No: Additional information' 41 Do you retain the right to modify your aggregate factors based on experience Yes: subsequent to the proposal? No: Additional Information: 42 Dwas your aggregate contract impose an annual maximum claim liability? If yes, Yes: identify the amount. No: If yes, please explain: Are there any other options available? Please explain. Yes: No: If yes, please explain: Request for Proposal Specific and Aggregate Stop Loss Insurance 43. Please describe the specific incurred I paid contract period (!.a,, 12J12.12/15, etc,) 12112 Yee No: that you offer. 12115 Yes: No 12118 Yes: No 15112 Yes: No 18112 Yes: No 24112 Yes: No Other. Additional Information: 44. What percentage, if any, of annual paid claims applies to Initial run-in firnhations on %: your aggregate contrac? MIA: Will your organization waive runn limitations? if yes, at what cost I Yes: percentage? rho If yes,: $ 1 Additional Information: 45. What is your minimum attachment point percentage or formula for first decreases? Does this differ for reasons? Yes: No: Additional Information: RENEWAL RESPONSES 4E. The client requires preliminary renewal information from their vendors 180 days in Yes'. advance of their actual renewal, Is your organization able to comply with this No: request? If no, explain. If no, please explain: Additional Information: 4? What Information do you require from the client, their claims administrator and / or Specific: Consultant to issue a renewal? Be specific regarding all clam experience and Aggregate: disclosure requirements. Additional Information 411. We require renewal rates and factors to be finalized no later than fourty five (45) Agree: days poor to the date of renewal. If disagree, explain, Disagree: If disagree, please explain, Additional Information: 49 What contract features are subject to adjustment from preliminary to final renewal? A) Yes: No: A) Specific Rate(s) ®}Yes: I No: B) Aggregate Factor C) Yes: No C) Aggregate Rate Other Additional Information: CLAIM REIMBURSEMENT RESPONSES 50 :What are your proof of calm and timely filing requirements for claim reimbursement requests? 51 What are your company's timing requirements with respect to notification and claim filing? 527 Who has final claim decision along authority with respect to specific and aggregate claims? 53 When do you consider a claim paid? Please be specific, 54 Who defines what the reasonable and customary amounts are? 55. Explain your organization's underwriting guidelines for incorporating plan changes, Must plan changes be approved in writing prior to implementation and I or renewal? Yes: No: Additional Information: Do you designers a Large Case Management firm with whom the claims Yes: administrator (or Pre -cart vendor) must =rumors potentially catastrophic cases? No: Additional Information, Request for Proposal Specific and Aggregate Stop Loss Insurance as any0 :1 there any corefiflone or circumstances (i.e., diagnosis, procedure, medical Yes: or services, etc.) that require pre -approval by your case managers? If yes, please list, v as No. o1w :57,qAre 11 yes, If yes, please list peas list: Additional Information: 58, Is there a Transplant Center of Excellence provision in your contract? Excellence Yes: Yes: No: o� Additional information: If so, is this a voluntary or mandatory program? Explain the oons:equenc!es of non- Yes: compliance. No: Additional Information If voluntary, do you offer any discounts for including it In the plan? Yes: No: If yes, please explain: Additional Information Are case management fees reimbursable to the client? Yes: No: Additional Information: Are caseomanagement fees included in an individual's lifetime maximum benefit 'a Yes: calculation? No: Additional Information: 66. Will you allow 'non-coverecy alternative care, if approved by your case Yes: managers? No: Additional Information: 61� Are there any charges anchor fees that standardly do not apply to specific or Yes: r2. aggregate coverage? No: Additional Information,6 Provide a listing of all specific conditions or diagnosis your organization considers to be 'catastrophliY. 69, If the client is a health care facility or provider (i.e., hospital, physician -group), are Yes: charges performed at their facility reimbursed at a lesser amount than other No: charges? If yes, please explain, Additional Information" 647- Does your contract recognize all eligible employees, spouses, rlouaafb; -partners, Yes: dependents, FMLA, retirees (If applicable), and COBRA beneficiaries as defined by No: the employees Plan Document I SPD? Arld'firrual I normalmn: 75-, Other than the employees Plan Document I PRO, does the contract allow for Yes: guidelines found in the employees Employee Handbook (I a, leave of absence No. policy)? Additional Information: 66. Is there ever a situation in which you would deny a claim that was a covered benefit Yes: in an employers Plan Document I SPD you had previously approved? No: Additional Information: 67. Please Identify any restrictions and limitations pertaining to an off- anniversary termination. Please detail the process involved in obtaining coverage for out--of-cantract services. 69. If PPO access fees are payable as a percentage of savings, are the -charges in Yes. excess of the specific deductible reimbursed? No Additional Information; 70-, Your contract must weiveActively at work' provisions, based upon -HIPAA Agree guidelines, Disagree: If disagree. please explain: Additiorm! Information: Request for Proposal Specific and Aggregate Stop Loss insurance TF- If a client acquires a new company dome the contract year, are you willing to waive Yes: the actively at work, dependent non -confinement and pxwtofij condition limitation No: provisions for the newly acquired employees, Mir dependents, spouses, domestic If no, please explairc partners, FMLA, retirees (it applicable), and COBRA beneficiaries? Additional Information: 727- The County requests that Plan Document I SFN be the controlling -document for all All contract provisions will minor M claim determinations. If your contract does not rely an the employees Plan Plan DocumenUSPD.: Document I SRO for stop loss claim determination, please explain your organization's itIon regarding coverage for the listed provisions. All provisions will NOT mirror the Plan DocumenUSPD,: If not please explain by provision. a) Work -related exclusions (workers compensation vs, any -gainful a) employment) We will match the Plan Document: The sto loss contract recalls: b) Pre-existing Conditions We will match the Plan Document: The I I Irecoils: a a c) Non -medically necessary charges c) C) We "W" mew h We will match the Plan Document: the pf� The co ass contract revails: The InG loss contra, 2M22E_ ch, Experimental and Investigational procedures, drugs or treatment ke.Z;9_n_t of of We Will Plan We will match the Plan Document: match the , Tire sto Ions con t recalls: a) Biologically -based mental disorders a) We will match the Plan Document The at D toss contract revolts: 0 we on as fj Non-bialogically-based mentaii/nenirrus, alcohol and subst - so ancee are 'a n 0 ,a We will match the Plan Document: The 5 loss contract recoils: he I wrap q g) Administrative, Investigative and legal services, including compensatory & g) punitive damages 'I the We will match due Plan Document! The At p loss contract revails: th Charges recoverable by a third -party (subrogation anchor Medicare) h) We will match the Plan Document The sto loss con recalls: 1) Expenses that are incurred as a result of war I) We will match the Plan Document, Ttte sto Mass contract recoils: I) Expenses that are incurred as a result of an act of terrorism on domestic and foreign sail We will match the Plan Document: The at D foss contract recalls: ' "a no "'a contract to Expenses incurred while committing assault! felony lo We will match the Plan Document �� The sto loss contract revolts: he at p loss contra revolts: 0 of 1) Charges related to attempted suicide 1) apt can We will match the Plan Document: The sto Loss can recalls: ad Charges related to self4rulicted injuries ad We will match the Plan Document: Tile sto loss cunt t recoils: ro Charges related to hazardous pursuits rd We will match the Plan Document: The sto loss contract recoils: a) Please include any other significant provisions you feel n addressed a) along with your arganization's position regarding those provisions, Request for Proposal Specific and Aggregate Stop Loss Insurance Identify whether your excess loss contract has any limits related to the following Coverage for all benefits in the employees Plan Document are covered provisions: under the stop loss contract: Coverage for all benefits in the employees Plan Document are NOT covered under the stop loss contract If there are limitations, please Provide detail by prevision, Limitation Detail b) Annual Open Enrollment Ild c.1 Section 125-qualified char�e in status events d) Domestic Partner coveage � escri a ! L - �ik . N _quirements and limitations) Erolagilcally-based menial disorders 1) Attempted suldide (whether sane or insane) k) Acts of terratism on domestic and fisw�n soil 1) Commission of a felony Additional comments SPECIFIC RESPONSES What is your organization' a average turnaround time for specific claims Days: submitted for reimbursement? Additional Information: With respect to specific claims submitted for reimbursement, please describe any limitations (i.e,, minimum dollar amounts), Is the maximum benefit for specific excess loss the Note lifetime Yes: maximum amount less the specific deductible? No: Additional Information: Do you offer advance funding or quick pay options for specific claims? If so, please Yes: provide details including any additional cost No: If yes, please explain: Additional Information: When do you require notification of a specific claim? % of Specific Deduction, or Amount of Claim: or Other, please explain: Additional Information: AGGREGATE RESPONSES It there is an aggregate clallm, is an audit part of your standard process? Yes: No: Additional information: What is your organkration's average tumaround time for aggregate claims DW& submitted for reimbursement? Additional Information: -- - -------- limitations (i.e,, minimum dollar amounts), Do you offer advance funding or quick pay options draggregate claims before end Yes: of plan year? If so, please provide details, including any additional cost, No: It yes, please explain: Additional Information: How often do you require aggregate claim reporting information? HEALTHCARE REFORM RELATED RESPONSES Clinical Trials How do �ou comply with the guidance regardIng_Indijoation in clinical trials? Request for Proposal Specifle; and Aggregate Stop Loss Insurance External Review Appeals Under health care reform, non-grandfathered plans must include an external review option. A claim filed in a timely manner (consistent with the requirement of the stop - loss policy) and denied by the claim administrator is subject to appeaL A clahn property incurred and adjudicated (denied) in one coverage period and subsequently appealed by the participant, including an external review, could easily extend beyond that coverage period. does your organization address claims that were denied In one coverage d and paid In another coverage period? ATURE: understand and hereby certify that all Information provided in this RFP respowe scument is due and cormwL I am autherized to represent and Rod my company to won responses, - 77MIkaw ■ behalf of(Company Name I Address): WMM= ATTACHMENT I - STOP LOSS PRICING FORM 15112 CONTRACT BASIS Compact "exhibit by entering the PEPM Cast for your quotas for each of the options requested. Please enter your assumed enrollment for each rate type and use this in detemitning your estimated annual premium ends, Enter your monthly e5gnmled eninument in A 37 STOP LOSS INSURANCE (Vendor Nartual sument med POLICY PROVISION Option 1 Option 2 Option 3 En ift Sto Loa S !go Deductible S30d OOa S404 mom Lifetime Maximum Unllrnited Unlimited Unlimited i Term t5112 15112 15112 ifie Prtcln Si In 05 $SS $SS On In ee + 5 SSS $$S $$S Free to ee+Child ran SSS SSS $$S Em la a wend 5 Cain smile S A ate Ste Lass Corridor 125% 125% 125� Annual Maximum Unlimited Unlimited Unlimited Pall Te 16112 16112 16112 A ate Pricin St to SSS SSS SSS Em I he o- S „e SSS 55S SSS Em I + Child ran $$S 5114 $SS On to ee + Fe nll SSS $SS tSS Gam site SSS SSS SS3 re ate Factor Gain site SSS S5S 5SS Annual Attachment Factor 5SS 55S 5SS 'fatal PEPM Stet Laa$e Peeenieaen 0.@t} 0.00 OR Estimated EnTelmerIC 1621 TOTAL ESTIMATED ANNUAL PREMItl� $C1 Sit so COSTS Performance Gualreashism State guarantee and amount at r m all Undordwiting Contingencies and Assumptions In this Section C) C) M C O C .C) C) CM CD O C) CDC) C) C) O O) C) CA O O Cif C) C) O cm O O O) m 0 0 to tO O 0 cq LO LO u? 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Please be brief - If you receive an offer message you have exceeded the space alloted for your reponse. please shorten your response to fit the available space. If you cannot complete your response In the space allocated, you will have the opportunity to provide supplemental In on Incther sections of your Proposal (TAB 6). Proposer Name: r1upubul rmsdn. Proposer Telephone: How long has your a anizalian n in business? Year established: anon:Additional info Has your company dens business under ether names? If yes, ple e provide Yes: historical background wlth assoxxclatedd venders n: fines, etc) Have you ever been suspended from writing this line of coverage? Yes: If yes please describe. No: if yes, please explain: 2. Is your organization licensed to do business in all 50 states and U 7S territories? if Yes no, identify the stalesnerfitories in which you are not currently licensed. No, if no, Pease explain: 3. What percentage of the risk does your company assume? % It less than 100%, please loan* additional reinsurers) and the respective If less than 100%, please explain percentage of assumed liability. Request for Proposal Specific and Aggregate Stop Loss insurance In what month do your reinsurance treaties renew? Month: Additional Information: 4. How many excess loss clients do you currently have? 9 of Clients: Additional information How much annualized premium do these clients represent? $ Additional Information 5 Please provide your current A K Best Rating and Financial Size Category. AM Best: Financial Size CategoRn Additional Information: 6. Please describe your disclosure process for pre -sale and at renewal (if different), Pre -Sala: Renewal: Additional Information: 7. Please provide a copy of your reinsurance contract and any amendments lncluded; Yes: No: Additional Information: When was the enclosed contract adopted? Please provide a copy of your disclosure statements Included Yes: No: Additional Information 8. In most cases, we require that your organization work directly with out Consultant Agree: rather than our client's claims administrator (TPAs, BCBS plans, carriers, etc.) on Disagree: such things as: Additional Information Renewals Specific & Aggregate contract concerns Plan DocumenUSPD adoption I approval Plan amendments PROPOSAL RIESPONSSS g. What is the minimum group size for which your company will issue a proposai? Employee Lives: Additiona'.:nfiermation, What Industries (if any) does your company consider to be'preferre? Please list, 11, What industries (if any) does your company consider to bei'moligible"? Please list. 12, For public wonder, do you have any restrictions on percentages of certain types of % employees, such as police and fire employees? N/k Additional I rimmusion: i:L Is your organization able to work with any claims administrator (TPAs. DCAS plans, Yes: carriers, etc?) No: If no, provide a listing of all U S. based claims administrators with whom your If no, please explain: organization will do business Please also indicate those that may have a'preferrod' status and describe the advantage to the client in do up business with these ce ms administrators. 14. Is your orgarazation's excess loss contract guaranteed renewable? Yes: If no, describe your determination and notification methods, No: If no, please expla rt Additional I nformation: Request for Proposal Specific and Aggregate Stop Loss Insurance 15, Does your second year contract automatically renew as a paid contrad? Yes: No: If no, please explain: Additional Information: 16, Is your organization capable and willing to contact the claims administrafter (TPAs, Yes: BCBS Mans, carriers, AD,) or Case Management firm directly to obtain additional No: information related to large claimants? Additional Information; 17-, When do you consider claims experience to be fully credible? Please descrftko. Specific: Aggregate: Additional Information: TF- Coverage is based on a ma -less I no -gain full transfer of coverage basis. If -disagree, Agree: please explain. Disagree: If disagree, please explain: Additional Information: 19-, We require firm rates at least 120 days Par to a&. If disagree, please explain, Agree: Disagree: If disagree, please explain: 20, Our Consultant creditors cmemge to�ba 'Wursy Men the.mw.carder Is In receipt Agree: of 11W bluder check or flart niershe-purkrw p"I and averaged 6ppk4m Do :�6 Disagree: Amagres wiift1hkv04Wwe If disagree, please explain: ii diestereae, moah. 21, me Onccec r firm or rates are presented and coverage is bound, under which circumstances, if any, would your organization modify rates / factors mid year? 22. Are you able to propose, a terminal liability option for a group that may, at some point Yes: in the future, choose to convert to a fully4roured arrangement? No: Additional Information: What is the cast to include this option? Cost: $ 1 as I me or: additional: A Additional Information: Is this option available at initial policy issue and also at renewal? Yes: No: Additional hibernation: 121 Does a your b your organization offer 'preforredi'micing based upon the client's Yes: networkisf? No: Additional Information; I if Yes, order list, f yes, provide a listing of the networks your organization has rated; identify the status level for each and the associated percentage of savings discount Space is provided for four (4) Network& If necessary, list additional networks under Network Name I Status Level I % Of Savings 'Additional Information*, 2 3 4 Additional Information: 24. What is your range of commissions offered? Specific: Aggregate: Can you provide rates net of commission? Additional Information: Request for Proposal Specific and Aggregate Stop Loss Insurance 2& "'a" Do you require that the prospective client purchase additional lines of coverage in 0 "in require Yes: order to hire stop loss coverage with your organization? If yes, outline your ""a "so No: ants requirements, If yes, please explain: D Do you offer Do you offer pricing consideration when multiple lines of coverage are purchased? If Yes: so, please provide details. d' No: If yes, please explain: 26 Do you limit the percentage of covered lives that are COBRA and / or -retirees? If Yes: yes, please provide details. No: If yes, please explain: What is the minimum individual specific deductible your company offers? $ Additional Information: 2& What percentage discount I credit is applied to your "first year(112J12) specific moving? 29. How long are your specific rates guaranteed? ths?a? 11 11 Are you willing to guarantee these rates for a period longer than twelve months? Yes: yes, will this impact rates? If yes, how so? No: If yes, please explain- , 3 36, Please describe the specific incurred/paid contact periods (i.e., 12/12, 12112 Yes: No: 12/15, Mc,) that you offer. 12115 Yes: No: 12118 Yes: No: 15112 Yes: No: 18112 Yes: No: 24112 Yes: No: Other, Additional Information 31,_ Is there a run-in limit on specific stop less? if yes, what is one percentage or formula? Yes: No: if yes, please explain: Additional Information 32, What is the maximum individual lifetime maximum amount your contract recognizes Unlimited Yes: No: as eligible dw,, $2 million, $5 million, unlimited)? $ million per individual Additional Informabom Do you have more than one option available? Yes: No, Additional Information: 33, Confirm that your specific coverage(s) can include the following benefits: A) Yes: No: A) Medical B) Yes; No: B) Prescription Drug C) Yes: No: C) Vision D) Yes: No: 0) Dental Bit Yes: No: E) Short Term Disability Other Additional Information: 34. Do you laser individuals at policy inception? Yes: No: Additional Information: Do you laser individuals at renewal? If yes, indicate whether this, applies only to Yes: those Insured under the initial contract terms, or if potentially large claimants are 1 No: reviewed annually. If yes, Mason, explain: If you do not laser, will you laser upon request and offer a lower premium? Yes: No: Additional Information: 11� Request for Proposal Specific and Aggregate Stop Loss Insurance If you do laser, will you offer a prenturn Increaseoclead of the laser? Yes: No: Additional Information: 35. Dom yourorgarnzation offer the specific deductible on a standard, aggregating and I Standard., or family basis? Aggregation: Family: Other, Additional Information: AGGREGA7E RESPONSES What percentage discount I credit is applied to your "first yeard a,, 1121ti aggregate pricing? 17 How long is your aggregate premium guaranteed? Are you wil'ing to guarantee these rates for a Forms -onger than twelve months? If Yes: so. how would this impact rates? I No: if yes, please explain: 38. Please describe the aggregate mocred I paid contract periods (t.e., 12112. 12112 Yes: No: 12/15, etc.) that you offer. 12/15 Yes: No: 12/18 Yes: No 15112 Yes: No 18/12 Yes: No 24112 Yes: No Other. Additional Information. 39. Confinn that W.r aggregate coverage can nclude the fAlowing benefits: A) Yes: No: A) Medical B) Yes: No: B) Prescription Drug C) Yes: No: C) Volon D) Yes: No: 0) Denta-.- E) Yes: No: 5) Short Term Disability Other, Additional information: 40. At what percentage of expected claims can the aggregate corridor be set? 110%; 115%� 120% 125W Other. Can you quote more than one option? Yes: No: Additional information' 41 Do you retain the right to modify your aggregate factors based on experience Yes: subsequent to the proposal? No: Additional Information: 42 Dwas your aggregate contract impose an annual maximum claim liability? If yes, Yes: identify the amount. No: If yes, please explain: Are there any other options available? Please explain. Yes: No: If yes, please explain: Request for Proposal Specific and Aggregate Stop Loss Insurance 43. Please describe the specific incurred I paid contract period (!.a,, 12J12.12/15, etc,) 12112 Yee No: that you offer. 12115 Yes: No 12118 Yes: No 15112 Yes: No 18112 Yes: No 24112 Yes: No Other. Additional Information: 44. What percentage, if any, of annual paid claims applies to Initial run-in firnhations on %: your aggregate contrac? MIA: Will your organization waive runn limitations? if yes, at what cost I Yes: percentage? rho If yes,: $ 1 Additional Information: 45. What is your minimum attachment point percentage or formula for first decreases? Does this differ for reasons? Yes: No: Additional Information: RENEWAL RESPONSES 4E. The client requires preliminary renewal information from their vendors 180 days in Yes'. advance of their actual renewal, Is your organization able to comply with this No: request? If no, explain. If no, please explain: Additional Information: 4? What Information do you require from the client, their claims administrator and / or Specific: Consultant to issue a renewal? Be specific regarding all clam experience and Aggregate: disclosure requirements. Additional Information 411. We require renewal rates and factors to be finalized no later than fourty five (45) Agree: days poor to the date of renewal. If disagree, explain, Disagree: If disagree, please explain, Additional Information: 49 What contract features are subject to adjustment from preliminary to final renewal? A) Yes: No: A) Specific Rate(s) ®}Yes: I No: B) Aggregate Factor C) Yes: No C) Aggregate Rate Other Additional Information: CLAIM REIMBURSEMENT RESPONSES 50 :What are your proof of calm and timely filing requirements for claim reimbursement requests? 51 What are your company's timing requirements with respect to notification and claim filing? 527 Who has final claim decision along authority with respect to specific and aggregate claims? 53 When do you consider a claim paid? Please be specific, 54 Who defines what the reasonable and customary amounts are? 55. Explain your organization's underwriting guidelines for incorporating plan changes, Must plan changes be approved in writing prior to implementation and I or renewal? Yes: No: Additional Information: Do you designers a Large Case Management firm with whom the claims Yes: administrator (or Pre -cart vendor) must =rumors potentially catastrophic cases? No: Additional Information, Request for Proposal Specific and Aggregate Stop Loss Insurance as any0 :1 there any corefiflone or circumstances (i.e., diagnosis, procedure, medical Yes: or services, etc.) that require pre -approval by your case managers? If yes, please list, v as No. o1w :57,qAre 11 yes, If yes, please list peas list: Additional Information: 58, Is there a Transplant Center of Excellence provision in your contract? Excellence Yes: Yes: No: o� Additional information: If so, is this a voluntary or mandatory program? Explain the oons:equenc!es of non- Yes: compliance. No: Additional Information If voluntary, do you offer any discounts for including it In the plan? Yes: No: If yes, please explain: Additional Information Are case management fees reimbursable to the client? Yes: No: Additional Information: Are caseomanagement fees included in an individual's lifetime maximum benefit 'a Yes: calculation? No: Additional Information: 66. Will you allow 'non-coverecy alternative care, if approved by your case Yes: managers? No: Additional Information: 61� Are there any charges anchor fees that standardly do not apply to specific or Yes: r2. aggregate coverage? No: Additional Information,6 Provide a listing of all specific conditions or diagnosis your organization considers to be 'catastrophliY. 69, If the client is a health care facility or provider (i.e., hospital, physician -group), are Yes: charges performed at their facility reimbursed at a lesser amount than other No: charges? If yes, please explain, Additional Information" 647- Does your contract recognize all eligible employees, spouses, rlouaafb; -partners, Yes: dependents, FMLA, retirees (If applicable), and COBRA beneficiaries as defined by No: the employees Plan Document I SPD? Arld'firrual I normalmn: 75-, Other than the employees Plan Document I PRO, does the contract allow for Yes: guidelines found in the employees Employee Handbook (I a, leave of absence No. policy)? Additional Information: 66. Is there ever a situation in which you would deny a claim that was a covered benefit Yes: in an employers Plan Document I SPD you had previously approved? No: Additional Information: 67. Please Identify any restrictions and limitations pertaining to an off- anniversary termination. Please detail the process involved in obtaining coverage for out--of-cantract services. 69. If PPO access fees are payable as a percentage of savings, are the -charges in Yes. excess of the specific deductible reimbursed? No Additional Information; 70-, Your contract must weiveActively at work' provisions, based upon -HIPAA Agree guidelines, Disagree: If disagree. please explain: Additiorm! Information: Request for Proposal Specific and Aggregate Stop Loss insurance TF- If a client acquires a new company dome the contract year, are you willing to waive Yes: the actively at work, dependent non -confinement and pxwtofij condition limitation No: provisions for the newly acquired employees, Mir dependents, spouses, domestic If no, please explairc partners, FMLA, retirees (it applicable), and COBRA beneficiaries? Additional Information: 727- The County requests that Plan Document I SFN be the controlling -document for all All contract provisions will minor M claim determinations. If your contract does not rely an the employees Plan Plan DocumenUSPD.: Document I SRO for stop loss claim determination, please explain your organization's itIon regarding coverage for the listed provisions. All provisions will NOT mirror the Plan DocumenUSPD,: If not please explain by provision. a) Work -related exclusions (workers compensation vs, any -gainful a) employment) We will match the Plan Document: The sto loss contract recalls: b) Pre-existing Conditions We will match the Plan Document: The I I Irecoils: a a c) Non -medically necessary charges c) C) We "W" mew h We will match the Plan Document: the pf� The co ass contract revails: The InG loss contra, 2M22E_ ch, Experimental and Investigational procedures, drugs or treatment ke.Z;9_n_t of of We Will Plan We will match the Plan Document: match the , Tire sto Ions con t recalls: a) Biologically -based mental disorders a) We will match the Plan Document The at D toss contract revolts: 0 we on as fj Non-bialogically-based mentaii/nenirrus, alcohol and subst - so ancee are 'a n 0 ,a We will match the Plan Document: The 5 loss contract recoils: he I wrap q g) Administrative, Investigative and legal services, including compensatory & g) punitive damages 'I the We will match due Plan Document! The At p loss contract revails: th Charges recoverable by a third -party (subrogation anchor Medicare) h) We will match the Plan Document The sto loss con recalls: 1) Expenses that are incurred as a result of war I) We will match the Plan Document, Ttte sto Mass contract recoils: I) Expenses that are incurred as a result of an act of terrorism on domestic and foreign sail We will match the Plan Document: The at D foss contract recalls: ' "a no "'a contract to Expenses incurred while committing assault! felony lo We will match the Plan Document �� The sto loss contract revolts: he at p loss contra revolts: 0 of 1) Charges related to attempted suicide 1) apt can We will match the Plan Document: The sto Loss can recalls: ad Charges related to self4rulicted injuries ad We will match the Plan Document: Tile sto loss cunt t recoils: ro Charges related to hazardous pursuits rd We will match the Plan Document: The sto loss contract recoils: a) Please include any other significant provisions you feel n addressed a) along with your arganization's position regarding those provisions, Request for Proposal Specific and Aggregate Stop Loss Insurance Identify whether your excess loss contract has any limits related to the following Coverage for all benefits in the employees Plan Document are covered provisions: under the stop loss contract: Coverage for all benefits in the employees Plan Document are NOT covered under the stop loss contract If there are limitations, please Provide detail by prevision, Limitation Detail b) Annual Open Enrollment Ild c.1 Section 125-qualified char�e in status events d) Domestic Partner coveage � escri a ! L - �ik . N _quirements and limitations) Erolagilcally-based menial disorders 1) Attempted suldide (whether sane or insane) k) Acts of terratism on domestic and fisw�n soil 1) Commission of a felony Additional comments SPECIFIC RESPONSES What is your organization' a average turnaround time for specific claims Days: submitted for reimbursement? Additional Information: With respect to specific claims submitted for reimbursement, please describe any limitations (i.e,, minimum dollar amounts), Is the maximum benefit for specific excess loss the Note lifetime Yes: maximum amount less the specific deductible? No: Additional Information: Do you offer advance funding or quick pay options for specific claims? If so, please Yes: provide details including any additional cost No: If yes, please explain: Additional Information: When do you require notification of a specific claim? % of Specific Deduction, or Amount of Claim: or Other, please explain: Additional Information: AGGREGATE RESPONSES It there is an aggregate clallm, is an audit part of your standard process? Yes: No: Additional information: What is your organkration's average tumaround time for aggregate claims DW& submitted for reimbursement? Additional Information: -- - -------- limitations (i.e,, minimum dollar amounts), Do you offer advance funding or quick pay options draggregate claims before end Yes: of plan year? If so, please provide details, including any additional cost, No: It yes, please explain: Additional Information: How often do you require aggregate claim reporting information? HEALTHCARE REFORM RELATED RESPONSES Clinical Trials How do �ou comply with the guidance regardIng_Indijoation in clinical trials? Request for Proposal Specifle; and Aggregate Stop Loss Insurance External Review Appeals Under health care reform, non-grandfathered plans must include an external review option. A claim filed in a timely manner (consistent with the requirement of the stop - loss policy) and denied by the claim administrator is subject to appeaL A clahn property incurred and adjudicated (denied) in one coverage period and subsequently appealed by the participant, including an external review, could easily extend beyond that coverage period. does your organization address claims that were denied In one coverage d and paid In another coverage period? ATURE: understand and hereby certify that all Information provided in this RFP respowe scument is due and cormwL I am autherized to represent and Rod my company to won responses, - 77MIkaw ■ behalf of(Company Name I Address): WMM= ATTACHMENT I - STOP LOSS PRICING FORM 15112 CONTRACT BASIS Compact "exhibit by entering the PEPM Cast for your quotas for each of the options requested. Please enter your assumed enrollment for each rate type and use this in detemitning your estimated annual premium ends, Enter your monthly e5gnmled eninument in A 37 STOP LOSS INSURANCE (Vendor Nartual sument med POLICY PROVISION Option 1 Option 2 Option 3 En ift Sto Loa S !go Deductible S30d OOa S404 mom Lifetime Maximum Unllrnited Unlimited Unlimited i Term t5112 15112 15112 ifie Prtcln Si In 05 $SS $SS On In ee + 5 SSS $$S $$S Free to ee+Child ran SSS SSS $$S Em la a wend 5 Cain smile S A ate Ste Lass Corridor 125% 125% 125� Annual Maximum Unlimited Unlimited Unlimited Pall Te 16112 16112 16112 A ate Pricin St to SSS SSS SSS Em I he o- S „e SSS 55S SSS Em I + Child ran $$S 5114 $SS On to ee + Fe nll SSS $SS tSS Gam site SSS SSS SS3 re ate Factor Gain site SSS S5S 5SS Annual Attachment Factor 5SS 55S 5SS 'fatal PEPM Stet Laa$e Peeenieaen 0.@t} 0.00 OR Estimated EnTelmerIC 1621 TOTAL ESTIMATED ANNUAL PREMItl� $C1 Sit so COSTS Performance Gualreashism State guarantee and amount at r m all Undordwiting Contingencies and Assumptions In this Section