Item C15o
i11
7— +: �. ,+ +i`
AGENDA1! } NG: Approval t+ advertise
„ Solicitation
for + + + for Md+
Party Administrationincluding Claims Administration,;;n; d Utilization
Review Services, Disease Management (DI Network
Related Management, Programs,
ITEM BACKGROUND: In February 2011, the BOCC granted approval to advertise an RFP for third
party claim administrator (TPA) of the County's self -insured health plan, which would include the
provision of + program, utilization review, and related ancillary services. In
October 2011. the BOCC approved the selection of Florida Blue Cross and Blue Shield (Florida Blue)
as thcTPA. The Administrative Services Agreement between Florida Blue and Monroe
effective+vember 1, 2011, provided that the initial term of .. r would be +
years, through September 30, 2014, and that the Agreement would automatically renew for two (2)
additionalone-yearCounty FloridaBlueofits intent not to renew. The
Agreement is now in the first of those two possible extensions. 1be current extended term will expire
on October 31, 201 S.
STAFF RECOMMENDATIONS: Approval
Appmxlmste for
adverfislaff
TOTAL O # 1 U INDIRECT COST: BUDGETED:
DIFFERENTIAL OF
adverthing
COST It 11 i) SOURCE OF FUNDS:
REVENUE PRODUCING: Yes — No AMOUNT PER MONTH Year
APPROVED
i 1.OMB/Purchasingl RiskManagement 6*�
DOCUMENTATION: Included
DISPOSITION:
REQUEST FOR PROPOSALS
•
MEDICAL THIRD PARTY ADMINISTRATIO
SERVICES I
CLAIM ADMINISTRATION, CASE MANAGEMENT AND
UTILIZATION REVIEW SERVICES, DISEASE MANAGEMENT
(DM), NETWORK MANAGEMENT, WELLNESS PROGRAMS,
AND OTHER RELATED SERVICES
■ . ■ OF COUNTY COMMISSIONERS
Danny L. Kolhage, District
Heather -Mayor Pro Tern, - District
George- David Rice,District
Murphy,Sylvia J.
COUNTY ADMINISTRATOR
Roman GaSteSl
CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION
Amy Heavilin Employee Benefits
March 24, 2015
j
EXHIBIT B
EXHIBIT C
EXHIBIT 11!
EXHIBIT E
EXHIBIT F
ATTACHMENTS: A.
MEDICAL PLAN BOOKLET
MEDICALB. D ENROLLMENT BY MONTF
C.
LARGE • REPORTMEDICAL
D.
CENSUS
E.
.. EQUIVALENTS
F
RESOLUTION 0 1 •9 8
• , • k • . -,•.• -
Lga
The Monroe County Board of County Commissioners wishes to receive competitive proposals
for its PPO Medical Plan Administration, including: claim administration, case management and
utilization review services, Disease Management (DM), network management, wellness
programs, and other related services as set out in the Scope of Services — Attachment W, for
its current Self -insured Medical Benefits Plan.
There is no request for Pharmacy Benefit Management Services at this time. The County
contracts with EnvisionRx for Pharmacy Benefit Management Services. PPACA requires the
County to integrate the pharmacy claims with the medical claims to calculate maximum out of
pocket amounts for participants. Special consideration will be given to proposals that will allow
the County to contain costs, maintain integration of the medical and pharmacy claim data,
and provide medical benefits that match the current benefit design.
It is critical to the County that the overall medical plan is well coordinated and effective in
the delivery of services to its employees, retirees, and their dependents. Proposers must
demonstrate that they can effectively coordinate with other service providers, how they
can integrate necessary data, and what the administrative cost of this integration will be.
The County anticipates that this contract will be awarded for an effective date of
January 1, 2016 or earlier, if possible. The initial contract term may be up to thirty six
(36) months and the County may elect to renew for up to two (2) additional
consecutive 1 year terms. The contract term will be dependent upon the acceptability
of premium guarantees, coverage, service, provider stability and market conditions.
The County is requesting Proposals only for Medical Third Party Administration
Services as follows:
Proposals are requested to be submitted net of commissions, although it is not required.
If any compensation for an agent is included in the rates, this must be fully disclosed
long with the exact services the agent will be providing to the County. Please note that
any entity and/or person who participated in the drafting of this RFP is disqualified from
submitting a proposal in response to this RFP or receiving a commission as a result of
the award of a contract for services arising out of this RFP.
:mia �r:IT
3 of 29
I I V1411eizFIV-1 C-A or_ I L IN 11 Lai I I I III
Contribution rates for the Fiscal Years 2012/2013 through 2014/2015 are included in
Attachment E — Rate Equivalents. Rates do not include commissions.
The current plan is administered by Florida Blue, which has provided coverage since
2011. With the Implementation of Florida Blue as the TPA, the County achieved
-sw,;WtZ&%rL1 1 9-
They are committed to maintaining strong network access, aggressive cost controls,
effective medical management programs, and transparency.
Prior to moving to Florida Blue, the PPO plan was administered by Wells Fargo, with
Precertification/Utilization Review provided by Keys Physician Hospital alliance (KPHA).
Networks were provided at that time through KPHA and the Dimension Health Plus
Network in South Florida, with Multiplan as a wrap network.
The County has not carried Stop Loss coverage for the Medical Plan since it dropped
the coverage in 2001.
Compensation: Proposer shall be in compliance with Section 624.428, Florida
Statutes. If any commissions and/or service fees are included in your rate quotation,
you shall specify the amount of the commissions and/or service fees, to whom they may
be paid and your reason(s) for including them.
The consultants are paid a fee from the County for these services and are not eligible to
receive a fee or commission from any proposer or to submit a proposal on behalf of any
agency, broker, or carrier with regard to this RFP.
• Coordination of Benefits
• Subrogation/Right of Reimbursement
• Pre -Admission Certification
• Prior authorization for certain procedures
• Care Coordination for facility admissions
• Care Consultants: one-to-one support and guidance with health care ne
• Condition Management for medical conditions
• 24x7 nurse line for questions
• Prenatal health management program
• Diabetes health management program
• Clinical prior authorization for certain physician or facility administered
medications
• Onsite biometric screening for all participants with outreach as warranted
• Onsite presentations on health related topicsiconditions
• Wellness program consultant to help design programs
5 of 29
4. Evaluation Criteria
A Selection Committee will be convened to review the Proposals and recommend which
Vendor should be selected for the project. The successful Proposer will be selected based on
the folloWng criteria.
20 points
10 points
overall costs (total financial impact to the County for
55 points --awarded based
administrative costs and claim costs I savings
on the following criteria.
guarantees)
0 Total ASO Fees and multiple year guarantee (3 year
0 ASO Fees -
level fees preferred)
maximum 10 points
0 Claim Costs - points to be awarded for the lowest
0 Claim Costs -
anticipated claim costs based on the following criteria:
maximum 45 points,
o CPT Code and Hospital pricing analysis
with equal weight
performed by the Consulting Actuary
between the 3
o Network Discounts, specifically with regard to
categories
Monroe County and including proposed
points apiece)
hospital and professional services.
o Discount Guarantees, including the calculation
methodology, the amount of discounts
guaranteed, and the financial risk to the
vendor.
Ability to provide the Scope of Services. The poi-nTs-tor
20 points
this criterion will be assigned based on both the
responses/compliance to the Scope of Services and the
overall information included in the Proposal. This criterion
will evaluate both quantitative and qualitative information
including:
Qualifications of Proposer and staff; availability of staff
Types and description of programs offered: Disease
Management, Case Management, Utilization Review,
Wellness Programs, Network Management, etc.
Performance guarantees, including the amount of
I
fees at risk and the methodology for calculating
whether the guarantee has been met.
Location of firm (local preference if applicable: up to 5
5 points
,addonal points) -
Total points earned are on a scale of 1 - 120 points
I = lowest 120 = highest
County Administrator who will ultimately make a recommendation to the Board of Coun
Commissioners regarding which Proposer should be hired.
Requests for additional information or clarification relating to the specifications of this
Request for Proposals shall be submitted in writing directly to:
Maria Fernandez -Gonzalez, Benefits Administrator
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
Facsimile (305) 2924452
All requests for additional information must be received no later than 3:00 PM, April 8,
2015. Any requests received after that date and time will not be answered. All requests
for additional information will be answered via an addendum to the RFP, which shall be
distributed to all interested Proposers on the schedule listed above. Oral requests will
not be answered.
All addenda are a part of the contract documents and each Proposer will be bound by
such addenda, whether or not received by him/her. It is the responsibility of each
Proposer to verify that he/she has received all addenda issued before responses are
opened.
11 I. We M*1
The Proposal submitted in response to this Request for Proposals (RFP) shall be
printed on 8-1/2" x 11" white paper and bound; shall be clear and concise, tabulated,
and provide the information requested herein. Statements submitted without the
required information will not be considered. Responses shall be organized as indicated
below. The Proposer should not withhold any information from the written response in
anticipation of presenting the information orally or in a demonstration, since oral
presentations or demonstrations may not be solicited. Each Proposer must submit
adequate documentation to certify the Proposer's compliance with the County's
requirements. Proposer should focus specifically on the information requested.
III] OW JT�j 1101111111:MI-1 1IL-7AS) 0 9 9 4
•
r - r
Proposer shalprovide a statement ad■ ■ each item below and supply
evidence in this Tab that demonstrates• ■
qualifications.
• The Proposer shall be licensed in the State of Florida to provide the requeste
• The Proposer shall have an A.M. Best rating of A- or higher and a financial siz
category of or higher.
• If the Pro!• . -..a by Best1, — A.M. Best rating belowa.
Proposer must submit three (3) years of independent audited financk
• The Proposer must provide a current (Statement of Standards for Attestatio
Engagements) SSAE 16 report, reflecting the evaluation of the Suitability (
Design and Operating Effectiveness of Controls for the processing of Healt
Care Claims.
• The Proposer shall provide a minimum of five (5) customer references for whic
they have provided Medical Third Party Administration Services within the pa.,
three (3) years. At ! /thesereferences mustbe / other
county governments of a similar size within the State of Florida. Each referenc
at _minimum shall include:
o -andfull addressof
o Name, address, title, and telephone number of the client contact;
of Identificationof -s providedincluding years forthe service
were offered
• The Proposer shall include at least three (3) letters of reference from clieni
which describes the services performed and the client's satisfaction with th
services provided. Letters of reference are preferred, however, if the Propos(
desires to include surveys completed by clients regarding the service of th
Proposer, be considered. Documents fromgovernmental/public
clients are preferred. • acceptable.
awardedOnly those Proposers who provide references along with their Proposal will be
points.
If your response indicates that you "can comply with deviations", you must fully explain
the deviations in this Tab.
8of29
Please include the completed Questionnaire (Exhibit B) under this tab in the file format
as provided in the RFP package. Responses should be succinct while providing
sufficient information to reply to the specc question. Claim projections are to be basel
on the historical claims information provided with this RFP. Excessive language is not
desired.
All Fees for the services described in this RFP shall be included in EXHIBIT F - Pricing
Exhibit. The total fee shall be an all-inclusive cost for the services proposed. The fees
should all be stated on a Per Employee Per Month (PEPM) basis. No addonal costs
or fees will be paid, including but not limited to travel costs, per diems, telephone
charges, facsimile charges, and postage charges.
It is not anticipated that contingencies will be included in the Proposal. However, pleas
include your underwriting assumptions under this Tab, immediately after the Pricing
Exhibit.
Tab 5. Staffing for this Project and Qualifications of Key Personnel
The Proposer shall describe the composition and structure of the firm (sol
proprietorship, corporation, partnership, joint venture) and include names of persor
with an interest in the firm.
shall identify any sub -contractors that will be used, if awarded this contract. T
Proposer shall describe the qualifications for each employee on the project team a
identify his/her role on the team. If sub -contractors are to be utilized, Proposer mu
clearly specify the role of each sub -contractor and provide evidence of th
qualifications. Include in this section the location of the main office and the location
the 1
office proposed to work on this project.
Resumes of all key members of the account team who will be assigned includi
professional designations and copies of licenses and diplomas are to be included und
tWis Tab. 1
kfT.T.IlMMMI =et -4r Information E
Tab 6 shall include:
• Exhibit C — Network Disruption;
• Exhibit D — Benefit Comparison;
• Exhibit E — CPT Code Worksheet;
• GeoAccess Reports; and
• Excel List of PPO network providers as described in Question 16 of
the Questionnaire.
Proposer shall provide any additional project experience not already
partner, principal, controlling shareholder or major creditor of
any other entity that failed to perform services or furnish goods
similar to those sought in the request for competitive solicitation.
f. Credit references (minimum of three), including name, current
address and current telephone number.
Proposer shall complete, execute, and attach the forms specified below
which are located in Section Two in this RFP, as well as a copy of a
business tax receipt from the Tax Collector's Office and shall include it in
this section,
• Submission Response:
• Lobbying and Conflict of Interest Ethics Clause
• Non -Collusion Affidavit
• • Free Workplace Form
• Public Entity Crime Statement
• Any Proposer claiming a local preference as defined in Monroe
County Ordinance 023-2009 must complete the Local Preference
Form ! attach to the Proposal.
A. Only complete sets of Documents- issued and shall be used in
errorspreparing responses. The County does not assume any responsibility for
or - _ _ _ ■ from - use of incompletesets.
C. Each Proposer •• • - for obtaining all Addenda for■ i
for acknowledging receipt of all Addenda on the RESPONSE FORM.
gm
Mum in-
1 l of 29
Proposals shall be automatically rejected. It is the sole responsibility of each Proposer
to ensure its Proposal is received in a timely fashion.
A. NON -COLLUSION AFFIDAVIT. Any person submitting a proposal in
response to this invitation must execute the enclosed NON -COLLUSION
AFFIDAVIT. If it is discovered that collusion exists among the Proposers,
the proposals of all participants in such collusion shall be rejected, and no
participants in such collusion will be considered in future proposals for the
sa7re work.
B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the
convicted vendor list following a conviction for a public entity crime may
not submit a proposal on a contract to provide any goods or services to a
public entity, may not submit a proposal on a contract with a public entity
for the construction or repair of a public building or public work, may not
submit Proposals on leases or perform work as a contractor, supplier,
subcontractor, or contractor under a contract with any public entity, and
may not transact business with any public entity in excess of the threshold
amount provided in Section 287.017, Florida Statutes, for CATEGORY
TWO for a period of 36 months from the date of being placed on the
convicted vendor list. Category Two: $25,000.00
C. DRUG -FREE WORKPLACE FORM: Any person submitting a bid or
proposal in response to this invitation must execute the enclosed DRUG -
FREE WORKPLACE FORM and submit it with his/her proposal. Failure to
complete this form in every detail and submit it with the bid or proposal
may result in immediate disqualification of the bid or proposal.
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.
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.
The Proposer is required to be familiar with and shall be responsible for complying with
all federal, state, and local laws, ordinances, rules, professional license requirements
and regulations that in any manner affect the work. Knowledge of business tax
requirements for Monroe County and municipalities within Monroe County are the
responsibility of - 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
01
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 fir
WEel 3 r • ••
Written modifications will be accepted from Proposers if addressed to the entity
and address indicated in the Notice of Request for Competitive Solicitation and received
prior to Proposal due date and time. Modifications must be submitted in a sealed
envelope clearly marked on the outside, with the Proposers name and
"MODIFICATION TO Proposal for Medical Third Party Administration Services." If sent
by mail or by courier, the above -mentioned envelope shall be enclosed in another
envelope addressed to the entity and address stated in the Notice of Request for
Proposals. Faxed or e-mailed modifications shall be automatically rejected.
• __3 I q I Wd• •
The Proposer is solely responsible for all costs of preparing and submitting the
response, regardless of whether a contract award is made by the County.
The County reserves the right to reject any and all responses and to waive
technical error and irregularities as may be deemed best for the interests of the County.
Responses that contain modifications that are incomplete, unbalanced, conditional,
13 of 29
obscure, or that contain additions not requested or irregularities of any kind, or that do
not comply in every - •-ct with the Instruction to Proposer,. be rejected at the
option of - County.
17. PROPRIETARY AND CONFIDENTIAL INFORMATION
All Proposals received as a result of this RFP are subject to Chapter 119,
Florida Statutes and will be made available for inspection by any person in
accordance with Florida Statutes. Any Proposer asserting that any portion of its
Proposal is confidential or exempt from disclosure under Florida's public records
laws must specifically identify the portions of the Proposal asserted to be
confidential and must provide specific citations of the Florida Statutes that
establish the confidentiality or exemption.
All material that is designated as exempt from Chapter 119 must be submitted in
a separate envelope, clearly identified as "PUBLIC RECORDS EXEMPT" with
your name and the Proposal name marked on the outside. If that material is
reguested through a public records reguest, the Counly will notify the Proposer of
the re uest and give the Proposer five 5 calendar days to obtain a court order
blocking the production of the material. If court order is not issued during that
time to block the production, the material will be produced.
By your designation of material in your Proposal as "Public Records Exempt',
you agree to defend and hold harmless the County fromjudgments,
damages, costs, and attorney's fees and costs of the challenger and for costs
and . : -y's fees incurred by the County by reasonof any legal•-
challenging your designation.
Please be advised that the designation of an item as exempt from disclosure as a
Public Record may impact the ability of the Evaluating Body to adequately
assess a Proposal and may therefore affect the ultimate award of the contract.
A. The County reserves the right to award separate contracts for the services
lased on geographic area or other criteria, and to waive any informality in any
.-esponse, or to re -advertise for all or part of the work contemplated.
B. The County also reserves the right to reject the response of a Proposer
who has previously failed to perform properly or to complete contracts of a similar
nature on
- -• _ •. r ■ 11_ •^ M- - '- Wit. • ! r
• • • • ! I. _ ! - - ! • ! ! -
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 havimy
an agent for service of process in the State of Florida. Companies shall have an A.M.
Best rating of VI or better, The required insurance shall be maintained at all times while
Proposer is providing service to County.
Statutory Limits
Employers' Liability Insurance
Bodily Injury by Accident $100,000
Bodily Injury by Disease, policy limits $500,000
Bodily Injury by Disease, each employee $100,000
General Liability, including
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
M=1
$200,000 per person
$300,000 per occurrence
$200,000 property damage
5rofessional Liability $1,000,000 per Occurrence
$2,000,000 Aggregate
The Proposer to whom a contract is awarded shall defend, indemnify and hold
harmless the County as outlined below.
The Proposer covenants and agrees to indemnify, hold harmless and defend
Monroe County, its commissioners, officers, employees, agents and servants from any
and all claims for bodily injury, including death, personal injury, and property damage,
including damage to property owned by Monroe County, and any other losses,
damages, and expenses of any kind, including attorney's fees, court costs and
expenses, which arise out of, in connection with, or by reason of services provided by
the Proposer or any of its Subcontractor(s), occasioned by the negligence, errors, or
other wrongful act or omission of the Proposer, its Subcontractor(s), their officers,
employees, servants or agents.
•
In the event that the service is delayed or suspended as a result of the
he re�kuired insurance. the Vendor
ahall indemnify the County from any and all increased expenses resulting from such
lelay.
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 mr
way limited to, reduced, or lessened by the insurance requirements contained
elsewhere within this agreement.
4 11111111111111111114,14 :Flo] I k N [a] 111101 Z01 L' 11-11 1
The County intends to make an award to the Proposer that has complied with tha
terms, conditions and requirements of the RFP. Any agreement resulting from this RFP
must be governed by the laws of the State of Florida, and must have venue established
in the State of Florida. The agreement will be submitted to the Monroe County Board of
County Commissioners for final approval.
��� a .
A M
Mlltl=o IPJMOI,.l IM lam
—RESPONSE•'
RESPOND TO: • -• • BOARD OF •UNTY COMMISSIONERS
Purchasing Department
GATO BUILDING, ROOM 2-213
tr SIMONTON
FLORIDAKEY WEST, t-0
I have included:
• Response Form
• Lobbying and Conflict of Interest Clause i
• Non -Collusion Affidavit 13
• Drug Free Workplace Form
• Public Entity Crime Statement
• Copy of business tax receipt from the 13
Tax Collector's office
• Local Preference Form (if applicable)
..i . .1111. . . . . ,.'
APPLICANT ORGAN
l *`
(Registered business name must appear exactly as it appears on www.sunbiz.org).
.. . S . . �. .. . ■i . r . ' a _ o :
Fees for services included in contract (total PEPM Administration Fees) per Exhibit F: $
Total Projected Incurred Claims for 1/11/20115 through 12/31/2015: $
Proposed • aunts: Professio
•amount
The fee is an all-inclusive cost. No additional costs or fees vvill be paid, including but not limited to travel
costs, per diems, telephone charges, facsimile charges, and postage charges.
(Print Name)
STATE 4
COUNTY •
Witness:
Telephone:
FR_
Subscribed and sworn to (oraffirmed) before _ • -:
(date) . .He/She
is personally known
to me or has produced (type of ■- . as
identification.
NOTARY
My Commission Expires:
ETHICS CLAUSE
44161110 11 AA J'M Z4 1 IT-,
R%aEam"
(Company)
!j Uarr-je -T n 1141VA M r-1 F TW=iT--To ff oTd no VAJA
0 [41
term nate t s gree en wi ou and ay also, in Is 01
Agreement or purchase price, or otherwise recover, the full amount of any fee,
commission, percentage, gift, or consideration paid to the former County officer or
employee."
(Signature)
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by (name of affiant). HelShe is
personally known to me or has produced
(type of identification) as identification
NON -COLLUSION AFFIDAVIT
1, of the city of according to
law on my oath, and under penalty of perjury, depose and say that
1. 1 am •': 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 compeon;
5. The statements contained in this affidavit are true and correct, and made
with full knowledge that Monroe County relies upon the truth of the
statements contained in this affidavit in awarding contracts for said project.
STATE OF:
COUNTY OF:
(Signature)
Date:
E INTO 221 on. A
My Commission Expires:
DRUG -FREE WORKPLACE FORM
ME=
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies
that:
20 of 29
1. Publishes a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is
prohibited in the workplace and specifying the actions that will be taken against
employees for violations of such prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the
business' policy of maintaining a drug -free workplace, any available drug
counseling, rehabilitation, and employee assistance programs, and the penalties
that may be imposed upon employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual
services that are under bid a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a
condition of working on the commodities or contractual services that are under
bid, the employee will abide by the terms of the statement and will notify the
employer of any conviction of, or plea of guilty or nolo contendere to, any
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of
the United States or any state, for a violation occurring in the workplace no later
than five (5) days after such conviction.
5. Imposes a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program if such is available in the employee's
community, or any employee who is so convicted.
6. Makes a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with
the above requirements.
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
0] 1 N!11 174
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
n4afts.
(Signature)
671rAt4us
r916111,91RUKA
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:
MONROE COUNTY,FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
Indemnification and Hold Harmless
.:
• .
The Contractor covenants and agrees to indemnify and hold harmless Monroe Coun
Board of County Commissioners from any and all claims for bodily injury (includin
death), personal injury, and property damage (including property owned by Monr
County) and any other losses, damages, and expenses (including attorney's fees) whi
arise out of, in connection with, or by reason of services provided by the Contractor
any of its Subcontractor(s) in any tier, occasioned by negligence, errors, or oth
wrongful act of omission of the Contractor or its Subcontractors in any tier, th
employees, or agents.
In the event _ completion of project isincludethe workof others) delayed
!.
expensessuspended as a result of the Contractor's failure to purchase or maintain the requir
insurance, the Contractor shall indemnify the County from any and all increas
resulting from
delay.
The first ten dollars ($10.00) of remuneration paid to the Contractor is for t
indemnification
• • for above.
requirementsThe extent of liability is in no way limited to, reduced, or lessened by the insuran
contained
elsewhere within this agreement.
__.._.
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.
.n 333ition, Me Contrac.
.ess than:
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.
AND
Prior to the commencement of work governed by this contract, the Contractor shall
obtain General Liability Insurance. Coverage shall be maintained throughout the life of
the contract and include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Expanded Definition of Property Damage
MEMEMM
$200,000 per Person
$300,000 per Occurrence
r; r1A I , S ■All - . 7-
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made
policy, its provisions should include coverage for claims filed on or after the effective -
date of this contract. In addition, the period for which claims may be reported should
extend for a minimum of twelve (12) months following the acceptance of work by th.:
County.
The Monroe County Board of County Commissioners shall be named as Additiona'
Insured on all policies issued to satisfy the above requirements.
AND
services
Ifl 11f . -1,1#1 111 .7! -.- -
CommissionersThere will be times when it will be necessary, or in the best interest of the County, to
deviate from the standard insurance requirements specified within this manual.
Recognizing this potential and acting on the advice of the County Attorney, the Board oY
County nd
-. authorization to Risk Management_
modify• -
Specifically excluded from this authorization is the right to waive:
• The County as being named as an Additional Insured — If a letter from the
Insurance Company (not the Agent) is presented, stating that they are unable or
unwilling to name the County as an Additional Insured, Risk Management has
not been granted the authority to waive this provision.
71711
waiverWaiving of insurance provisions could expose the County to economic loss. For this
reason, every attempt should be made to obtain the standard insurance requirements.
If a ..desired,Request
• .--. and submitted for consideration
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
execution by
Should Risk Management ,r this WaiverRequest, - party- an appealwith the County Administrator or - Board of CountyCommissioners,retainsY decision -making
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of
Insurance Requirements, be waived or modified on the following contract:
Contractor:
Contract for:
Address of Contractor:
Phone:
Scope of Work:
on for Waiver:
Policies Waiver
will apply to:
Signature of Contractor:
Approved Not Approved
Risk Management:
Date:
County Administrator appeal:
Approved Not Approved
Date:
Board of County Commissioners appeal:
Approved Not Approved
Meeting Date:
M 27,91 txpm
SIGNATURE
11[#1@IQ; Dj a* AV] tA74
A. Vendors claiming a local preference according to Sec. 2-349, Monroe County Code must complete
this form.
Name of ProposevResponder 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 fumish copy.)
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.
TITUT01 MI -
Print Name:
STATE OF
COUNTY OF
On this - day of _, 20_, before me, the undersigned notary public, personally appeared
.............................................. , known to me to be the person whose name is subscribed above or who
Notary Public
... . .......
Print Name
My commission expires: ........................................ . Seal
Exhibit p` of
The Proposer be evaluated on compliance with the below service requirements. i
o.� ..� - - .� r. - ,.tween the
p
Deliverables: If necessary, the Proposer shall provide an Amendment, Endorsement, or Rider to
accommodatethe County to non-standard isions agreed to by the Proposer.
Checki Ie box for each service offered.Only provide explanationsif you cannot comply
fully i requested service.
s No Yes, Can Comply but with
Serviceit Specified i ti
ComplyComply tail deviations
low
is t s all v
y and construedin accordance
with the laws of the Stateof Florida
applicable tmade
and to be performedl in the
State.
e Proposer shall maintain
compliance it Il federal, state,
localand laws, ordinances, rules,
professional license requirements
and regulations that in any manner s
affect the services o i _..._ - - - -
Provide pricing for the effective
to of the contract
information provided in the RFP.
Variations in actual
enrollment shall have n
effect on the proposal. The
proposal shall be vale
regardless of the final
enrollment mix, number of I
Awardees, number of plan
destqs, or outcome.
I charges for any service or optional
service clearly outlined in the
Pricing lit
Disclose y commissions an tar
service(if any are included) in
your rate quotation, including
amount f the commissions and/or
service s, to whom they may be
paid and your 5 (s) for including
them. Disclosuret be on an '
Exhibit A — Scope of Services 5
Yes No Yes, Can Comply but with
Service Requirement
Can Cannot Specified Deviations
(please detail deviations
Comply Comply below)
annual basis.
Provide a toll free number and
sufficient staffing to handle inquiries
directly from staff and plan members.
Provide an experienced
Implementation Manager
responsible for the accuracy and
Atimeliness oft i lamentation.
Provide an Account Manager
responsible fort overall
relationship.
Participate in open enrollment
meetings on an annual basis.
Participate in onsite meetings at
various County locations to
review plan results, as needed.
Duplicate and administer current
benefits.
Administer in -network and out of
network benefits.
Make timely and accurate claims
payments to medical providers in
accordance with plan provisions.
Provide billing & eligibility
services to the County
Accept enrollment via paper,
online enrollment, or electronic
files
Provide effective programs to
manage participant health as well
as claim costs.
Provide services, including but
not limited to:
• Coordination of benefits
• Subrogationtrecovery
• Fraud investigation
• Utilization Review
Exhibit A — Scope of Services 2015
Yes No Yes, Can Comply but with
Service Requirement
Can Cannot Specified Deviations
(please detail deviations
Comply Comply be lowl
Integrate Large Claim
Management, Case Management,
and Disease Management
services to provide seamless and
effective care and cost
management services to the
County and its Partic' ants.
Report potential large claims with
sufficient detail for the County to
anticipate increased costs.
Provide monthly detailed claims
reports to the County and the
consultant electronically.
Provide appropriate reports to
assist with mandated State and
Federal filings.
Provide ad hoc reports, upon
request, at no charge.
Provide integration of the
Pharmacy claims with the
medical claims for consolidated
calculation of maximum out of
_Rgpk t A�amoqnts.
Provide prior authorization of
specific procedures, such as
advanced imaging (MRI, CAT
scans, PT, OT, Speech Therapy,
Home Health, etc.j.
—�—roVide
a 24 hour nurseline for
participants' use.
Provide outreach to members
with targeted conditions or risk
factors.
Solicit, screen, evaluate
credentials, and approve
providers to participate in the
network.
Secure discounts from networ
providers to enable the County to
achieve plan savings through
effective network contractin
Exhibit A — Scope of Services 2015
��q
Yes, Can Comply but Wit—h—
Yes No
Service Requirement
Specified Deviations
Can Cannot (please detail deviations
Comply Comply below)
Monitor and manage networks to
ensure sufficient coverage for all
medical services.
Collaborate with the County to
ensure continued network
satisfaction.
Ensure appropriate transition of
care tot County's plan
as needed,
-participants
Provide Health Risk Assessments
- online or in person - at least
once annually.
Provide Biometric Screening for
aII plan participants, at least once
annually.
Provide one-on-one health
coaching.
Provide onsite staff to drive the
development of Wellness
Initiatives.
Design, develop, and direct
Health Fairs for plan participants.
Design, develop and direct
empI oyee wellness. activities -
I t quarterly.
Provide outreach to employees
with critical scores on the
HRA/Biometric Screenings.
Provide the results of Biometric
screenings tot Claims
Administrator/ Disease
_MgaNement vendor.
Design, develop and direct
employee educational activities -
at least quarterly.
Provide estimated renewaF—rates
120 days in advance of renewal.
Produce and distdbute all
appropriate materials, including but
not limited to: enrollment
materials, plan booklets &
I
Exh i bit A — Scope of Services ' 2015
Yes No Yes, Can Comply but with
Service Requirement
Can Cannot Specified Deviations
(please detail deviations
Comply Comply below,)
schedules of beneffts, summa of
benefits (SBC's), provider lists, etc.
Provide sufficient time for the
County to review and approve all
open enrollment communication
materials prior to release to
_nAla yees.
Provide performance guarantees
With financial penalties for non-
performance. Performance
guarantees should include:
• Maintaining Network
Access
• Maintaining promised
discounts
• Claim turnaround time
• Claim payment accuracy
• Participant satisfaction
No party to this Agreement shall be
required to enter into any
arbitration proceedings related to
the reement.
Comply with the Florida Local
Government Prompt Payment Act,
Section 218.70, Florida Statutes.
The Provider shall submit to the
County an invoice with supporting
documentation in a form
acceptable to the Clerk. Following
receipt of the invoice, the County
will have 45 days to pay the invoice
without interruption of service,
The Proposer may terminate this
Agreement with ninety (90) days'
notice to the County.
The County may terminate this
Agreement with or without cause upon
thirty (30) days' notice to the Proposer.
County shall pay Proposer for work
performed through the date of
terminaton.
Exhibit A — Scope of Services 2015
Yes No Yes, Can Comply but with
Service Requirement
Can Cannot Specified Deviations
(please detail deviations
Comply Comply I I
be Owl
Agree to the following: "Pursuant to
Florida Statute §119.0701, Proposer
and its subcontractor's 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 one 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 of provide the records and
at a cost that does not exceed the cost
provided in Florida Statutes, Chapter
119 or as otherwise provided by law,
(c) Ensure that public records
that are exempt or confidential and
exempt from public records disclosure
requirements are not disclosed except
as authorized by law.
(d) Meet all requirements for
retaining public records and transfer, at
no cost, to Monroe County all public
records in possession of the Proposer
upon termination of this Agreement
and destroy any duplicate public
records that are exempt or confidential
and exempt from public records
disclosure requirements. All records
stored electronically must be provided
to Monroe County in a format that is
compatible with the information
technology systems of Monroe
The Proposer does hereby consent
and agree to indemnify and hold
harmless the County, its Mayor, the
Board of County Commissioners,
appointed Boards and Commissions,
Officers, and the Employees, and any
other agents, individually and
collectively, from all fines, suits, claims,
demands, actions, costs, obligations,
attorney's fees, or liability of any kind
arising out of the sole negligent actions
Aa er or ti I n�
Yes
No
Yes, Can Comply but with
SpecifiedDeviations
i it
Comply
it deviations
.......lay
................................. ww.....
unnecessary caused by the
willful nonperformance of the Pr os r
and II be solely responsible and
answerable for any andII accidents or
I
injuries to persons or property arising
out of its performanceof this contract.
The of and type of insurance
r overa,e recluirementsset forth
hereunder shall in no way bel
construed as limiting
l
indemnity set forth in this paragraph.
Further the Proposer agrees to defend
and pay all legal costs attendant to
b i
acts aftHbutable to the sole negligent
.act..........................has....r.......... .a....a......m�.m. _....................1.......................mm
� m � �fl.m.�
EXHIBIT B
Questionnaire
Self -Funded Questionnaire
Submit responses in Hard Copy and Electronic Version in
a useable Microsoft Word format.
For your convenience, Exhibit B is also available as a
separate downloadable document in a useable Microsoft
Word format.
Type of Coverage
.
P products
Driven prod
- 109111511111
Commercial
t . 4 0 11 r.. .- LI a1
Commercial Enrollment
Total Enrollment
. 4• /
-Commercial Enrollment
-- Enrollment�
Medicare
Total
3. What percent of yourFlorida enrollment in 2013and 2014 is frompublic sectorpercentage is fully-
IT.sure. .ed for 2014?
Total,Enrollment
Total
2013
Enrollment
Public
Public Fully- I
.
Sector
o; d
i
Provide a c. r' of youraccreditation
contract19. Indicate your contract status for your top ten hospital providers (by number of admissions) as well as your top ten
physiciantphysician group providers (by number of encounters) in Miami -Dade County Only. Indicate the current
1 thecontractsit f If differ 1,,networksproposed, please complete1 each
network proposed.
r r fi
N
Contract
Contract
Date U
Physicians/
Date of
! r'
Expiration
ian
Status
Expiration
Date
Contract'.
contract
g:! -
Change
�m
-
0 Complete following table for Monroe 1Miami-Dade Counties.your current provider panel.
number of individual providers, not offices).
Provider Type
Monroe County
-----------------------
Miami -Dade County
Cardiologists
1 1Surgeons
Chiropractors
Dermatologists
--------------------
Endocrinologists
General Surgeons
HIVAIDS Physicians that specialize in HIVAIDS
treatment
InfectiousGeriatricians
'.. ! 1."!
Number of
Percentage of
Percentage of
Percentage of
PCPS
SpecialtyNumber
r r
Specialty
Physicians Board
Board -
Accepting
r e
NumberPatients
r '' rNumber
of
Numberof
Number of
Numberof
r
r
Of
Urgent
HospitalsHospitals
r
Acute
Care
Offering
Offering
Facilities
Tertiary Care
Inpatient
Care
Hospitals
BehavioralCare
Agencies
Health Care
22. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and radiology) affiliated with network
hospitals contrac,1 Yes• If no,any hospital phygroup(s) / !:' - 4: Please / _ -..
schedules
24. What fee schedule do you use for out -of -network benefits on the PPO plan? Can you administer alternate fee
!o1request?
25. Are PCP and Specialist contracts evergreen? Yes — No — If no, what are the termination requirements within
your provider contracts as far as timeframes and notification?
M. /I.:- -
Gainesville, Florida
ME -
NUM
Orlando, Horida
MFIN1#7111111191
1111111, iq�ipiiii'11111111111, 111111 1111111�1111 I lip ;1I �1111 111111 1111111 111 1! 1 1111111 11 11 1�111 III
Provider Type
Miami -Dade
Ambulatory Surgery Centers
Bone Density Testing
N1 "OFIN
DME Providers
Home Health Care Agencies
Hospice Agencies
. rogm -
Mammogram Facilities
Occupational Therapists
Outpatient Laboratories
Physical Therapists
Rehabilitation Facilities (Inpatient)
Speech Therapists
N. Do you offer a high quality/low cost network of hospitals and physicians? Provide the quality and cost indicators
employed to designate high -quality hospitals/physicians.
Network - Innovations
30. What types of Accountable Care Organization (ACO) or similar programs/models do you have in place already anij
what do you have planned for 2015 and 2016? Will any of these programs be available to Monroe County's
participants?
31. Are there any costs/charges to the County in order for employees to receive care from an ACO or similar
program/model? If yes, what are the costs and how will it work?
32. When would the County realize a cost savings from implementing the ACO or similar program/model? How would
savings being shared between the parties (i.e. ACO, your company and the County)?
33. Who funds the incentive for the providers that participate in an ACO or similar program/model and how do they fund
it?
34. How will members determine which providers are participants of the ACO or similar program/model?
Plan Network — Behavioral Health
35. Will you allow Employee Assistance Programs (EAP) to be provided by another firm at the County's discretion? Yes
No
36. Describe your procedures and processes for integration of the County's EAR Can the County's EAP directly refer a
member to a Behavioral Health care provider? Yes — No _. If no, describe the process for the EAP to obtain
authorization for services.
37. What is the target and actual ratio of clinical staff to members (MD, Phl), LCSW, LMFT, LMHC and ARNP) In
Monroe County and Miami -Dade County?
38. Does your case management program provide patient -specific information back to the patient! s Primary Care
Physician? Yes —No
39. How would transition of care be handled for members currently under care with a provider that is not in your existing
network, including timeframes? How would transition of care be handled if a provider is terminated during the
course of treatment?
40. Are the "V codes" (i.e., marriage/couples/family counseling) covered? Yes — No _. Do they require prior
approval in order to be covered? Yes _ No_
41. Ust the Behavioral Health facilities under contract in South Florida (Monroe and Miami -Dade Counties).
42. Provide the number of Behavioral Health professionals (broken down by MD, Phl), LCSW, LMFT, LMHC and ARNP)
included in your South Florida (Monroe and Miami -Dade) network.
za
43. What percentage of your contract physicians are board certified in Psychiatry? %
44. What was the Monroe County and Miami -Dade turnover rate of your Behavioral Health network in 2013 and 2014?
Break down the turnover rate by MD, PhD, LCSW, LMFT, LMHC and ARNP for each year.
2013 201132014 2014
Monroe Miami -Dade Monroe Miami -Dade
ARNP
LCSW
LMIFT
LMHC
MD
PhD
Network Pricing
45. What is your overall network pricing as compared to prevailing Medicare reimbursement for hospitals and for v
physicians? Please answer separately for Monroe and Miami -Dade Counties. I
46. Do any network contracts include outlier provisions? Yes_ No , If yes, explain.
47. Are changes to your network pricing planned for 2015 or 2016? If so, describe.
48. The County intends to exclude claims payment for "Never Events" in the future and wants members to be held
harmless. Do all of your contracts include language to address non-payment and hold harmless for such events?
neu. mow does eacn nospilai repol!r�
how does the health plan oversee the protocol?
50. What database do you utilize to determine reasonable and customary (R&C)? What percentile do you use to pay
medical claims? How often is the database updated?
52. Indicate your current 2014 network payment method employed for each type of servicetproduct and networli
proposed. You may copy the chaq below for each additional network offered.
Provider Type/Service
E-21M
Adult Primary Care
F." 111"111 ro 7 7 1
Complex Imagin
Emergency Room
Hospital Based Providers
Anesthesia
Radiology
Pathology
, Emergency
Hospital Inpatient
Hospital Outpatient
Surgical
Non -Surgical
Obstetrics
WeArom
Pediatric
Eme mm
Urgent Care Center
oral'MH iand
Substance) Outpatient
53. Hospital Pricing Analysis for Monroe and Miami -Dade Counties. Complete the following tables for hospital
inpatient and hospital outpatient services based on your PPO book of business only, for the periods specified.
•.- 77#Em- . - M I , I , t =-v - 1: rM H ARIEUFM
Abupq) inpatient services:
TO-7r, Tj
AVERAGE COST
ALOS
AVERAGE COST
ALOS
PER DAY
TOTAL
PER DAY
IN NETWORK
IN NETWORK
TOTAL
UZI*
Intensive Care
AVERAGE COST
ALOS AVERAGE COST
2013
ALOS PER DAY
TOTAL PER DAY
IN NETWORK IN NETWORK
TOTAL
PPO PPO
PPO PPO
MedlcaVSUr ical
Matemi _
Neonatal
Intensive Care
CCUIPCU
Total
AVERAGE COST ALOS
AVERAGE COST
2014
ALOS PER DAY TOTAL
PER DAY
IN NETWORK IN NETWORK
TOTAL
PPO PPO PPO
PPO
Medical/Surgical
----
Maternity
Neonatal
Intensive Care
CCUIPCU
Total
Hospital Inpatient — Miami -Dade County
AVERAGE COST
ALOS AVERAGE COST
ALOS
2012
PER DAY
TOTAL PER DAY
IN NETWORK
IN NETWORK
TOTAL
PPO
PPO
PPO PPO
MedicallSur ical
Materni
Neonatal
Intensive Care
CCUIPCU
Total
AVERAGE COST
ALOS AVERAGE COST
2013
ALOS
PER DAY
TOTAL PER DAY
IN NETWORK
IN NETWORK
TOTAL
PP®_
PPO
PPO PPO
MedicallSur ical
Maternity
Neonatal
Intensive Care
CCUIPCU
Total
4 +! 4
1
4 AVERAGE
1 4
IN NETWORK
•
TOTAL
Neonatal
Average Allowed
Reimbursement Average Eligible Charge;
Amount Per
Net Effective
Type of Service
Method Per Encounter
Encounter
Discount %
PPOI PPOPPO
Surgery
$
%
Emergency Room
$
%
Radiology
$
$
%
Pathology
$
%
Therapy (PT10TIST)
$
$
%
Other
$
$
0
otal
Average d
Reimbursement1
.... -PW- Amount
Method
Per Encounter Encounter
Discount
EmergencySurgery
Room
Radiology
Pathology
Therapy
Other
Eligible charges are submitted charges less Ineligible charges such as duplicates, non -covered Items,
MethodNote:
Note: Reimbursement refers to case rates, flat fees, % of Medicare, Allowable, % Discount, etc.
54, Proposer must cR plot -,shouldbe based on average reimbursements for
ratesMonroe County and Miami -Dade County providers separately, NOT on statewide or MSA provider averages. Use
reimbursement 1
Miami-Dade55. Have you changed affiliations for ancillary services (diagnostic services, prescription drug benefits, etc.) in Monroe
or Counties during the past 12 months?describe such changes.
2,73K
64. Do you have a network management/provider services department that assists with provider issues? Yes_
No List the staff members/titles to be assigned to the County.
65. Where is the network management/provider services staff that services your South Florida (Monroe and Miami -Dade
Counties) network located?
66. Describe how your organization will communicate with providers the County's schedule of benefits, changes to the
schedule of benefits and general administrative policies and procedures specific to the Countys Medical Plan.
67. Describe how your organization will ensure that providers in your network refer to network facilities and other
network Providers.
Eligibility and Claims Administration
68. What is your average lag time for claims?
69. Are eligibility and claims administered on the same system? Yes-- No— If no, how are these functions
integrated?
70. Provide the location(s) where claims and eligibility will be processed for the County.
71. Will the County have a dedicated team for eligibility, claims and customer service? Yes-- No--
72. Do you plan on major changes or upgrades to your administrative system or the platform you are proposing for the
County in the next 24 months? Yes-- No-- If yes, please explain.
73. Will you provide the County with an eligibty contact person for eligibility file issues and questions? Yes__ No
74. What eligibility responsibilities does your organization expect the County to perform?
75. Are network contractsifee schedules loaded into your claims administration system or must claims be submitted
elsewhere for re -pricing?
76. Can your claims adjudication process block J Codes (except for neoplastic drugs from oncologists/bematologists) from
processing? How does your organization propose to educate your network on this process?
77. What percentage of your claims is submitted electronically by facilities? -0/a By physicians? %
78. What percentage of your claims submitted by facilities are auto adjudicated? _% By physicians?
79. Provide details on the system edits that are contained in your organization's claims processing system that assist
examiners in accurately processing claims. Indicate how your system adjusts for coding errors.
80. How does your claim system manage claims from sources that are specifically exc ' luded from payment according to
the plan booklet, such as: care provided by a relative; care provided for injuries caused by an act of war; care
provided for injuries caused during the commission of a felony?
81. Can your claim system integrate data from outside PIBM's to administer a combined maximum out of pocket? Is
there an additional charge for this?
Page 113
82. Describe your explanation of benefits (EOB) process. Are EOBs available hard copy and/or online? Is there any
flexibility?
83. What is included on the EOB statements? Do the EOBs reflect the prescription data if the client utilizes an outside
Pharmacy Benefit Manager?
84. Will you process run -out claims after plan termination? Yes _ No _ If yes, for how long? At what cost?
85. Are you wng to accept delegation of fiduciary responsibility with respect to claJrn adjudication under your ASO
contract? Yes — No _. Is there an additional charge for this?
86. What access will County auditors have to claims and administrative data necessary to complete an annual audit?
Describe any limitations.
87. Are you willing to allow access to a full claims audit, at your expense, in the event of significant performance issues?
No no, please explain.
Average days turnaround
---------------
Financial accuracy
im!=R mr1 ■•i .
Target Goal Actual Performance
% within days
------------- - - - -------------------
i.
% within days
■ Days Business Days
7� 11111 � 1111111 11� 1111111 11 ;111111 1
=111:1111ir 11�pii�111!11111111 I � 11 11111�11 11111111111�111
071 =5T=171111
Claim Policy I
Z�� El RMIRIM11111 I I 1 11 ' 11M I � i I . a , . 4
-f 79 lkm�!M I A J.
anesthesiologists, pathologists, etc.? What is reimbursement based on (i.e. U&C, Average contracted fees, average
charges, etc.)? Are participants subject to balance bng?
94. What percentage of claims submitted are denied for processing (pre -discount, pre -adjudication)?
a. number of claims denied/ total of claims submitted
b. dollars of billed charges denied /total billed charges submitted
95. What percentage of services was denied for medical necessity in 2013, 2014 and year to date 2015? Of those
denials, what percentage was appealed and subsequently approved? Describe what types (top 5) of services are
most frequently denied and why these services are denied.
Z=
b. Of the members in a., what percentage of them initially agrees to discuss their situation with the medical
management professional? This is the "participation rate".
c. Of the members in b., what percentage of them stays involved with the medical management
professional to the end? (For example, if a member agrees to work with a case manager or a health
coach, do they stay engaged until the case manager or health coach closes the case?)
108. In one page or less, outline your precertification program. Explain the nature of the program (i.e., notification,
notification and steerage, denials) and why you chose that particular approach. Also provide a list of services that
require pre -authorization or pre -notification and clearly identify which applies.
a. How many specific services do you include for precertification?
L Number
ii. Dollars
b. Of the services identified in a., what percentage of those services was altered (steered, denied, delayed
until another test was done, etc.)?
i. Number
ii. Dollars
N - 0
WSM �Vo C �&OJV 0�6, ILL TWM0AU7n- M" It- P-1=1LOM .- I
how the program is triggered (i.e. from Prior Authorization, Notificafion of admission, diagnosis, etc.).
-2. Of all hospital confinements, what percentage is subject to Rounding?
I. Number
ii. Dollars
b. Of the hospital confinements identified in a., what percentage of those confinements was altered
(transferred, discharged early, kept longer)?
1. Number
ii. Dollars
110. Is your Utilization Management (UM) service located in your claims office? Yes ® No _. If no, where is it
located?
111. What is the size of the UM staff in the claims office that you are proposing for the County?
112. Do you have a physician on staff to intervene on "problem" admissions or certifications? Yes — No
113. Describe the participant's responsibility for compliance with UM programs, in -network, out -of -network, and out -of -
area.
114. Are your utilization review service/requirements different in any way for in -network, out -of -network, or out -of -area
participants? if yes, please explain.
115. Do providers have access to your coverage positions or clinical guidelines? How?
116. Are network providers at risk for not following your Medical Management Program? Yes — No — Please
explain.
117. Describe how inpatient utilization is managed. Specifically address after hours, emergency, in and out -of -network.
Page 116
118. Is inpatient census reviewed on a daily basis? Yes — No— Ifno,howoften?
119. How do you communicate with patients and family members regarding length of stay and discharge planning?
120. In two pages or less, describe your Case Management Program.
121. Provide a copy of the appeals/denial case management process. Provide documentation to demonstrate
when/how these protocols are shared with providers and members.
122. How m any Case Managers do you have per 100,000 members? H ow m any active cases per case manager?
Average length of case?
123. Are there any cases the Case Management Program wi I] not manage? Yes ., No — If yes, describe.
124. Do members in Case Management have a consistent Nurse Manager presiding over each case? Yes — No
125. How is clinical progress communicated to patients and physicians?
126. Describe how providers and participants are made aware of Case Management.
127. What are your parameters s notifying the County of !h cost cases?
128. Do you report your Case Management results? Yes — No — If yes, include samples.
129. What are the readmission rates (within 30 days of discharge) for Monroe and Miami -Dade Counties?
130. What are the minimum qualifications for Clinical Case Managers and Utilization Management staff?
131. Will specific clinical staff members (such as MDs, RNs, LPNs, other) be assigned/dedicated to the County's
account for the purpose of case management and utilization review? Yes —No
132. Describe your medicalprotocols to determine:
a. Medical necessity
7 Medicalappropriateness
c. Experimental and investigational
Disease Management/Wellness
IndicateThe County Is requesting that Wellness and Disease Management programs be fully Integrated Into your pricing
proposal. Please respond to the questions below specifically with regard to the Initiatives Included In your base
ASO fee. If you offer additional services, please clearly indicate that they aresupplemental services and
1 for each of these services.
high-intensity133. In three pages or less, describe your disease management program. Include details on how your Disease
Management Programs remain current based on research and industry trends.
a. Intervention Model. How would you characterize your program? High reach, low intensity model? A
low reach, !f"l A nurse -based program? program?
b. Patient identification. What percentage of members is identified for intervention?
I. Through claims
ii. Through other programs (case management, wellness coach)
mily M-
Jill. WIT,
Milli alle](.4jillrAl!
135. With regard to specc diseases:
a. What diseases do you actively manage?
b. Do you use different interventionists for different disease states?
C. When do you begin to manage a particular disease? For example, with cancer do you offer assistance
at the time of diagnosis or during an active course of treatment?
136. Is your disease management group in house? If not, how does your subcontractor access patient benefits,
eligibility, etc.? How are services charged to the group?
i 11! 11 Rl irl l��l Jill
138. With regard to "Hand Offs and Overlaps", how does a hand off work? A hand off is when one part of the clinical
model needs to involve another part of the clinical model. How does case management interact with disease
management? Is it possible that more than one part of the clinical model is'louching" a patient at the same time? If
so, how is information shared between pads of the clinical model?
139. Are your Disease Management Programs accredited? Yes_ NcL___ If yes, by which accreditation organization
and status achieved?
TAI =17mml RN
Programs as of January 1, 2014 and January 1, 2015. Complete the table below:
As of January 1, 2014
As of January
1, 2 15
Nationally
South Florida
(Monroe and, Miami -
Dade) ...............
INIT:T11 end plill� III;] 111METTANE-41111811 I nsM!R Me- 14
145. Describe the type and number of staff professionals (PA's, LPN's, RN's and Nurse Practitioners) who will be
handling the County's members. How is the staff assigned to each case? Describe oversight/supervision by
physicians.
Page 118
146. Are patient's physicians notified of the Disease Management care plan? Progress or lack of progress?
147. All members in the Disease Management Program should have a specc nurse manager regardless of whether
they are suffering from one or more than one chronic condition. If there are exceptions, explain each.
148. How does your organization measure clinical impact of each Disease Management Program?
149. Please describe any evidence you have that demonstrates how your disease management program stands out
among the competition.
150. In three pages or less, describe your wellness program. Be sure to provide the basic nature of the program,
inclusive of the following: Participation rates, incentives, outcomes, and guarantees.
151. Patient identification - What percentage of members are identified for intervention?
a. Through claJms
b. Through other programs (case management, wellness coach)
152. Of the patients identified, how many are contacted by a medical management professional? For this question,
ucontacf is a LIVE allempt to contact a member by a medical management professional either through a phone call
to the member or to the member's spouse or the member's physician. If you have other means of contacting
members such as automated calls, mangs, text messaging or email blasts, please footnote them here.
153. Please describe any evidence you have that demonstrates how your wellness program stands out among the
competition.
154. Complete the chart below for each service your organization provides (check all that apply).
Provide examples of
your resources:
�'L �� i �lli ce
III
1 1 .
Seminars/One-
Wellness Services Telephonic on -One
Name of Vendor
Counseling
■
NW. ill
Blometric Screenings
Health Coaching
Lunch and Learns
.
0- 1 IM
Resource Facator
Follow Up Reports
2,731E
Women's Health
11 MMRIP. 11�
MEE=
Other: (identify)
162. Describe your capabilities to manage or offer the following (check all that apply):
MEN=
Co o r d I nate C ommunity Na -11 f Vendor
Partnership
77ns=iteinic
Lunch and Learns
Fitness Center Discounts
i 1 4,41 NTell 1191:111 RIM
Stress Management
(Yoga, Tal Chi, etc.)
1 Walking Programs
Other: (identify)
163. Describe the type of reporting you use to track, analyze and assess cost savings:
Quality Assurance
164. In two pages or less, describe your Quality Assurance program.
165. Provide specific examples as to how your objective measurement and information sharing process has improved
clinical and financial outcomes in South Florida over the past two years.
166, Describe the process to share information with providers, facilities and hospitals.
167. What clinical studies were conducted or evaluated in the past two years?
168. What interventions were put into place to improve outcomes as a result of the clinical studies?
169. Have any providers, facilities or hospitals in South Florida been sanctioned or terminated for quality reasons?
Yes _ No _ If yes, describe.
lCustomer Service
170. Provide a copy of your most recent member satisfaction survey results and indicate the following:
a. What percentage of survey participants were very satisfied or extremely satisfied with your plan?
170. How do you track verbal and written complaints received by your organization?
for all plan members (total population) and the County's members specifically? Yes — No —
172. How many verbal and written complaints were received per 1,000 members during 2012, 2013 and 2014?
Year Number per 1000
2012
2013
2014
173. Are the member grievances/appeals tracked and reported? Yes — No — If yes, are you able to provide the
County with a report capturing the number and types of grievancestappeals which are received from the County's
members?
174. Can your plan track and report on customer service activity? Tes — Ro —
175. Does your plan have a 24-hour toll free number for member services and provider services? Yes — No
no, what are the days and hours of operation?
176. Describe the services and features members have access to on your website?
177, How are providers instructed to handle members who have not yet been issued member ID cards?
178. Can you accommodate information from carve -out vendors for ID cards? Describe any requirements and
limitations.
179. How many ID cards will be distributed per family?
Page 122
111 11 1111
MINIMUM, 171� I T I � I I msm�=
Member Service
Target Goal
2014 Actual Performance
Average Speed of Answer
Average Length of Call
First Call Resolution Rate
Call Abandonment Rate
184. Describe online resources that are available specifically in South Florida (Monroe and Miami -Dade Counties) to the
County's members:
Member Online Resources Yes No Planned
Provider Directory
Links to Physicians' Websites
Claim Status
Claims History
Explanation of Benefits
Provider Performance Information (Hospital Comparison/Profiles)
Health Risk Assessment
Personalized Health Record
Plan Policies or benefit booklets
Personalized Health News/Information
Health Coaching
Ask a Nurse/Medical Questions
Disease Specific Chat Rooms
File Complaints
E-mail Member Service
Order Replacement ID Cards
Other
. .........
'lliust inaicate date of anticipatea impiementation.
Provider Fraud and Abuse
185. In one page or less, describe your provider fraud and abuse unit from a staffing, qualifications, and systems
perspective.
Page [ 23
d. A description (including any report samples) • the services you can provide the County to fund, monitor and
reconcile the self -funding account.
a. What do administrative costs (including network charges) represent?
L As a percent • claims?
ii. As a capitated dollar amount per employee?
201. Do you maintain an in-house subrogation unit to subrogate claims? Yes — No _. If not, please identify how you
propose to provide subrogation and recovery services to the County, including the charge to the County for this
se -vice.
202. Please describe your process for monitoring and identifying claims for which subrogation is appropriate. Please 12
specific with regard to system edits, clinical screening, research of public records, etc. that you use to ensure that
potential recoveries are pursued. i
203. Do you provide reports on subrogation and other recovery actives to the client? How frequently? Is there a
charge • this?
E04. Are there any charges to the client for subrogation, COB, third party recoveries? Yes — No _. Please iden0p
all charges associated with subrogation, COB, third party vendors, etc.
W,fm k a 92H. -4 k, 14 d h Itele] LTA u-'I'a &is] �
Definitions: DED-annual deductible
PAD - per admission deductible
PVD - per visit deductible
BPM - benefit period maximum
LTM - lifetime maximum ENTER PROPOSER INFORMATNON IN THIS CELL
RM
mm
am
om
Gallagher Benefit Services Network Evaluation Model
Sample Physician Fee Schedules
Average Negotia e
CPT4 Allowable Fee
Code IDescription IFF& I—
00740
Ancs-Ugi Endoscopy-Intro Prox Duod
00810
Anes-Low I ntest Endo -Dist To Duod
11100
Biopsy of Skin Lesion
17000
Destruc Premaig Lesion
17110
Destruc Wart Mollusc/ilia; Up 14
20550
Inj Tendon Shealth/Ligament
20610
Arthrocentesis Aspir&lInj; Maj Jnt
27447
Total knee replacement
31231
Nasal Endo Dx Uni/Bil Sep Proc
31575
Diagnostic Laryngoscopy
36478
Endovenous Laser I st vein
43239
Ugi Endo; W/Bx I/Mx
45378
Colonoscopy Flex; x-Sep Proc
45380
Colonoscopy Flex; W/Bx I/Mx
52000
Cystoscopy
59400
Routine Vaginal Delivery
59510
Cesarean Section
66984
Remove Cataract, Insert Lens
69210
Remove Impacted Ear Wax Uni
70553
MRI - Brain
71020
Chest X-ray, 2 Views
73630
X-Ray Exam of[ t
73721
MRI Jnt of Lwr Extrem w/o Dye
76830
Ultrasound Transvaginal
76942
Echo Guide for Biopsy
77052
Comp Screening Mammograrn
80050
General Flealth Panel
80061
Lipid Panel
81000
Urinalysis
-
=88305
Level Iv - Surg Path Gross&Mic Exam
-
P90460
Imadrn Any Route I St Vac/Tox
-
90471
Immunization Admin; I Vaccine
-
90649
I-Ipv Vaccine 4 Valent, [in
-
90670
Pneumococcal Vacc 13 Val Im
-
90806
Psychotx Ov/Op Behv Mod 45-50 Mn;
-
92012
Ophth Serv: Mud Exam; Interm Estab
-
92014
Ophth Serv: Med Exam; Comp Estab Pt
-
93000
Ecg-Routine 12 Lead; Wlint & Rpt
93306
Tic W/Dappler, Complete
-
95004
Perq W/Allerg Extract -Spec # Test
-
95165
antigen Therapy Services
-
96372
Ther/Proph/Diag Inj Sc/I
-
96413
Chemp, Iv Infusion, I Fir
-
97110
Therap I/> Areas/I 5 Min; Exercises
-
97140
Mnl TxTech II ore Rgns. Ea 15 Min
-
97530
Tx Actv it Pt Cute Prov Ea 15 Min
-
Gallagher Benefit Services Network Evaluation Model
Sample Physician Fee Schedules
Average NegOtla=
CPT4 Allowable Fee
Code IDescription EF PPG R&CI
41 Chiropractic Mani p Tx; Sp 3-4 Rgns - -
43 Chiro Mani p Tx; Extruspin I/> Areas - -
02 Ofe/Outpt E&M New Low -Mod 20 Min - -
03 Ofc/Outpt E&M New Mod -Sever 30 Min - -
0 Ofc/Outpt E&M New Mod -Hi 45 Min - -
05 Ofc/O t E&M New Mod -Hi 60 Min - -
E2 Ofc/Outpt E&M Estab Minor 10 in - -
13 OfelOuipt E&M Estab Low -Mod 15 in
14 Ofc/Outpt E&M Estab Mod -Hi 25 in
Is Ofc/Outpt E&M Estab Mod -Hi 40 Min
23 Init Hosp-Day E&M Hi Sevrity 70 in
32 Subs Hsp-Day E&M Minr Cmpl 25 Min
33 Subscit. Hcusp-Da y E&M Sig Cmpl 35 Min - -
43 Office Cash New/Estab Mod 40 in - -
44 Ofc Cask Mew/Estab Mod -Hi 60 Min - -
45 tie Cnslt New/Estab Mod -Hi 80 in - -
5 Initial lnpt Consult Mod -Hi 80 in -
83 Emerg Dept Visit E&M Moderate Sever - -
4 Er Visit E&M High Sever Urgent Eval - -
5 Er Visit E&M High -Sever Sig Threat - -
M Critical Care E&M; I St 30-74 in - -
95 Pr d Prev Med E&M Est Pt; 18-39 Yrs
96 Prd Prev Med E&M Est Pt. 40-64 Yrs
I "
11f
............. 111 iW ........
70450 Ct Head/Bruin; W/O Contmt. Mad
C1 74176 Abd & Pelvis W/O Contrast
74177 Ct Abdomen&Pelvis W/Contrast
188305
:Level Iv - Surg Path Gross&xam Mic E
88307,11,1111"I'Level V" Surg Path Gross/Micro Exam
L0427 Amb Srvc Is Ernerg Transport Levi I
L0429 Amb Service Bis Emergency Transport
L4230 Infus Set Ext Insulin Pump Nonndle
L9502 Radophnn Techtum Tc 99M Tetrofosmin
1745 Injection Infliximab 10 Mg
2505 Injection Pegfilgrastim 6 Mg
7302 Levonorgestrel Intrautern Cntracpt
9355 Trastuzumab 10 Mg
3854 Gene Expression Profiling Panel
)2048 Injection, doxorubicin HCL, lie2sornal, Doxil, 10 mg LI_
exhibitComplate, the aAdministrationr
NA In the call.
ALL PACKAGE THIS I AND MUST TOTALTHE err CHARGE FOR THE 11
IF YOU ARE OFFERING VARYING LEVELS OF SERVICE PLEASE PREPARE A SEPARATE PRICING EXHIBIT TO REFLECT EACH PACKAGE YOU ARE OFFERINa
Please enter the tale PEPM char" for all services quoted In line 74, Enter your monibly estimated enrollmord In line 72,
Z11414 ] t
CLAIMS ADMINISTRATIONrl
�
r
fflMtkzs1-w-
F
'
nn
s
a
�r . i.
H • nr
r
KfiffKA1,0141c-
T-
SET UP FEES - INCLUDE ALL
SET 11 IN
r�.
Enrollment
y,
i Enrollment etc.
Y
I
OTHER SERVICES
a
WI
Y
f
n
. S
44
Other (Grata &show '. f ,
WELLIVESS OG
HE FREQUENCIES
s
WelinessCr x q with County`■
: r
Health
Vag,KOM
f
t
Y ling
+i
3
, �i s + .;
RAWI.
r
a
r
ADDI
NAkT6E§N0fREPQRTED
TOTAL ADMINISTRATION FEES PEPM*
/' r r
TOTAL
BlueOptions
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
A Self -funded Group Health
Benefit Plan
For Customer Service
Assistance: (800) 664-5295
B0611 —111114
Divislons 001, of ROI, R02, 002
M4 Z
Section 1: How to Use Your Benefit Booklet ............................................................. 1-1
Section 2: What Is Covered? ..................................................................................... 2-1
Section 3: What Is Not Covered? .............................................................................. 3-1
Section 4: Medical Necessity .................................................................................... 4-1
Section 5: Understanding Your Share of Health Care Expenses .............................. 5-1
Section 6: Physicians, Hospitals and Other Provider Options ................................... 6-1
Section 7:
BlueCardo (Out -of -State) Program ........................................................... 7-1
Section 8:
Blueprint for Health Programs ..................................................................
8-1
Section 9:
Eligibility for Coverage ..............................................................................
9-1
Section 10:
Enrollment and Effective Date of Coverage ............................................
10-1
Section 11:
Termination of Coverage ........................................................................
11-1
Section 12:
Continuing Coverage Under COBRA .....................................................
12-1
Section 13:
Conversion Privilege ...................................................................
13-1
Section 14:
Extension of Benefits ..................................................................
14-1
Section 15:
The Effect of Medicare Coverage/ Medicare Secondary Payer
Provisions..............................................................................................
15-1
Section 16:
Duplication of Coverage Under Other Health Plans/Programs ...............
16-1
Section17:
Subrogation ............................................................................................
17-1
Section 18:
Right of Reimbursement .........................................................................
18-1
Section 19:
Claims Processing ..................................................................................
19-1
Section 20:
Relationship Between the Parties ...........................................................
20-1
Section 21:
General Provisions .................................................................................
21-1
Section 22:
Definitions ...............................................................................................
22-1
Table of Contents 0
Pill
This is your Benefit Booklet ("Booklet'). It
fescribes your coverage, benefits, limitations
Benefit Plan ('Group Health Plan" or "Group
Plan") established and maintained by Monroe
County BOCC.
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 AgreemenV),
to provide certain third party administrative
9 _Mw"Jer
service, and other services, and access to
certain of its Provider networks, BCBSF
i T
�411 TA
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.
before you need Health Care Services. It
contains valuable information about:
• your BlueOptions benefits;
• what is covered;
• what is excluded or not covered;
• coverage and payment rules;
Blueprint for Health Programs;
how and when to file a claim;
how much, and under what circumstances,
payment Mll be made;
what you will have to pay as your share; and
other important information including when
beneft may change; how and when
coverage stops; how to continue coverage if
you are no longer eligible; how benefits will
How to Use Your Benefit Booklet
Tecoo.. es—oyprdw-
�nd the Group Health Plan's subrogation
-ights and right of reimbursement.
NoT I VT M T Mrol = t -71 Me To I k M 7 -M M Me
pay for particular Health Care Services.
When reading your Booklet, please
remember that:
you should read this Booklet in its entirety in
order to determine if a particular Health Care
Service is covered.
the headings of sections contained in this
Booklet are for reference purposes only and
shall not affect in any way the meaning or
interpretation of particular provisions.
references to "you" or "your" throughout refer
to you as the Covered Plan Participant and to
your Covered Dependents, unless expressly
stated otherwise or unless, in the context in
which the term is used, it is clearly intended
otherwise. Any references which refer solely
to you as the Covered Plan Participant or
solely to your Covered Dependent(s) will be
noted as such.
references to "we", "us", and "our" throughout
refer to Blue Cross and Blue Shield of
Florida, Inc. We may also refer to ourselves
as"BCBSF".
if a word or phrase starts with a capital letter,
it is either the first word in a sentence, a
proper name, a title, or a defined term. If the
word or phrase has a special meaning, it will
either be defined in the Definitions section or
defined within the particular section where it
is used.
covered?what particular types of Aealth Care
Services are
Read the "What Is Covered?" and "What Is
Not Covered?" sections.
• how much will be paid under your Group
Health Plan and how much do you have to
pay?
Read the "Understanding Your Share of
Health Care Expenses" section along with the
Schedule of Benefits.
• how the amount you pay for Covered
Services under the BlueCard (Out -of -
State) Program will be determined when
you receive care outside the state of
Florida?
Read the "BlueCard (Out -of -State) Program"
section.
• how to add or remove a Dependent?
Read the "Enrollment and (Effective Date of
Coverage" section.
• what happens if you are covered under
this Benefit Booklet and another health
plan?
Read the "Duplication of Coverage Under
Other Health Plans Programs" section.
• what happens when your coverage ends?
Read the "Termination of Coverage" section.
• what the terms used throughout this
Booklet mean?
Read the "Definitions" section.
In-NetworkWhenever you need care, you have a choice. If you visit an:
Out -of -Network Provider
receiveYou receive In -Network benefits, the You Outhighest -of-Network
. .e available. benefits — you will share more of 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 - In -Network Provide
3' You should notify BCSSF of inpatient
i admissions.
■ i • •
• ■ •
. Services rendered In -Network • u-r located outside of ■ • you r
notify us of inpatient admissions.
How to Use Your Benefit 800klet t =2
1114018111L
that are covered under this Benefit Booklet. All
benefits for Covered Services are subject to
your share of the cost and the benefit
maximums listed on your Schedule of Benefits,
the applicable Allowed Amount, any limitations
and/or exclusions, as well as other provisions
contained in this Booklet, and any
Endorsement(s) in accordance with BCBSF's
guidelines then in effect.
Remember that exclusions and limitations also
apply to your coverage. Exclusions and
limitations that are specc to a type of Service
this section. Addonal 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.
a- - - - - - -
this section will be covered under this Booklet
only if the Services are:
I . within the Health Care Services categories
in the "What Is Covered?" section;
2. actually rendered (not just proposed or
recommended) by an appropriately licensed
health care Provider who is recognized for
payment under this Benefit Booklet and for
which an itemized statement or description
of the procedure or Service which was
rendered is received, including any
applicable procedure code, diagnosis code
and other information required in order to
process a claim for the Service;
3. Medically Necessary, as defined in this
Booklet and determined by BCBSF in
accordance with BCBSF's Medical
Necessity coverage criteria then in effect,
except as specified in this section;
4. in accordance Wth the benefit guidelines
listed below;
5. rendered while your coverage is in force;
and
6. not specifically or generally limited or
excluded under this Booklet.
whether Services are Covered Services under
this Booklet after you have obtained the
Services and a claim has been received for the
Services. In some circumstances BCBSF or
Monroe County BOCC may determine whether
Services might be Covered Services under this
Booklet before you are provided the Service.
For example, BCSSF or Monroe County BOCC
ITF - T TV
transplant is provided. Neither BCBSF nor
Monroe County BOCC are obligated to
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
amAltyea ir agent xf BCBSF *r Minr-re Cryn
BOCC, or by any other person, shall waive or
otherwise modify the terms of this Booklet and
therefore, neither you, nor any health care
r-rovider or other person shoyld rely in any sy
written or verbal representation.
What Is Cave 2-t
,.,ny other applicable payment rules specific to
particular categories of Services:
I . Payment for certain Health Care Services is
included within the Allowed Amount for the
primary procedure, and therefore no
additional amount is payable for any such
Services.
2. Payment is based on the Allowed Amount
for the actual Service rendered (i.e.,
payment is not based on the Allowed
Amount for a Service which is more complex
than that actually rendered), and is not
based on the method utilized to perform the
Service or the day • the week or the time of
■. the procedure is performed.
3. Payment for a Service includes all
components of the Health Care Service
when the Service can be described ■ a
single procedure code, or when the Servict
is an essential or integral part • the
associated therapeutic/diagnostic Service
rendered.
0 [a] d 1*1
I MM RI 2
or employment are covered.
■ are excluded.
Testing and desensitization therapy (e.g..
serum are covered. The Allowed Amount for
allergy testing is based upon the type and
number of tests performed by the Physician.
The Allowed Amount for allergy immunotherapy
treatment is based upon the type and number of
doses.
Ambulance Services
U-Till 97n - i LTA [1,MT1 mi toM 0 - 4 0 . a 0 4
I -
to transport you from:
_dwgwl�
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; •'
3. the travel distance involved in getting you to
the nearest Hospital that can provide proper
care is too far for medical safety, as
determined by BCBSF or Monroe County
BOCC.
per -day maximums for ground transportation
• air/water transportation.
Ambulatory ■ Centers
10e,-ft C2re Sejuices reidered at—ca ATrbulato1V
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
L drugs and medicines administered (exceV6
for take home drugs) at the Ambulatory
Surgical Center;
5. dressings, including ordinary casts;
117MR31 a a
7. administration of, including the cost of,
whole blood or blood products (except as
outlined in the Drugs exclusion of the What
M =.
9. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e..., EKG); ant
10. chemotherapy treatment for prov,
maligant disease. I
n
Anesthesia Administration Services
Administration of anesthesia by a Physician or
tEwhlai Xe&&Vral
may be covered. In those instances where the
CRNA is actively directed by a Physician other
than the Physician who performed the surgical
procedure, payment for Covered Services, if
any, will be made for both the CRNA and the
Physician Heafth Care Services at the lower
iirectet-se2r�ices
with BCBSF's payment program then in effect
for such Covered Services.
V
y an operating Physician, nis or ner pa
associate.
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
spewal-I 14-14-zy
consisting of-
1, well -baby and well -child screening for the
presence of Autism Spectrum Disorder;
Applied Behavior Analysis, when rendered
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
Was bee-m lost.
��srllrarrlr,? MT
I 11EET.
0 Y - - ILTRIMIM -.;=
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 denliedd.
of an Emergency Medical Condition.
WaNAW nali,74_77_1
identified as covered in this section.
Note: In order to determine whether such
Autism Spectrum Disorder Services are covered
under this Benefit Booklet, we reserve the right
to request a formal written treatment plan signed
by the treating Physician to include the
frequency and duration of treatment, the
What is Covered? 2-3
anticipated outcomes stated as goals, and the
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
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
cleft lip or cleft palate are covered. In order for
such Services to be covered, your Covered
Dependent's Physician must specifically
be medically necessary and consequent to
treatment of the cleft lip or cleft palate.
Clinical Trials
Clinical trials are research studies in which
Physicians and other researchers work to find
ways to improve care. Each study tries to
answer scientific questions and to find better
ways to prevent, diagnose, or treat patients.
Each trial has a protocol which explains the
purpose of the trial, how the trial will be
the beginning and end points of the trial.
If you are eligible to participate in an Approved
Clinical Trial, routine patient care for Services
the Approved Clinical Trial may be covered
when:
1. an in -Network Provider has indicated such
R_, = ��
2. you provide us Wth medical and scientific
information establishing that your
participation in such trial is appropriate.
Routine patient care includes all Medically
Necessary Services that would otherwise be
covered under this Booklet, such as doctor
visits, lab tests, x-rays and scans and hospital
YF- rj,
Schedule of Benefits.
Even though benefits may be available under
W-a �SXWW17-01WI�.. -�,f
Approved Clinical Trial you may not be eligible
for inclusion in these trials or there may not be
time you want to be included in a clinical trial.
Exclusion:
1. Costs that are generally covered by the
clinical trial, including, but not limited to:
a. Research costs related to conducting
the clinical trial such as research
Physician and nurse time, analysis of
results, and clinical tests performed •
for research purposes.
b. The investigational item, device or
Service itself. I
c. Services inconsistent with widely
accepted and established standards of
care for a particular diagnosis.
Concurrent Physician Care
Concurrent Physician care Services are
covered, provided: (a) the additional Physician
actively participates in your treatment; (b) the
Condition involves more than one body system
or is so severe or complex that one Physician
cannot provide the care unassisted; and (c) the
What Is Cwemd? 24
same specialty with different sub -specialties.
Consultations provided by a Physician are
consultation and the consulting Physician
prepares a written report.
Contraceptive Injections
Medication by injection is covered when
provided and administered by a Physician, for
the purpose of contraception, and is limited to
the medication and administration when
medically necessary.
Dental Services
Dental Services are limited to the following:
1 , Care and stabilization treatment rendered
within 90 days of an Accidental Dental Injury
to Sound Natural Teeth.
2, Extraction of teeth required prior to radiation
therapy when you have a diagnosis of
cance of the head and/or neck.
3. Anesthesia Services for dental care
including general anesthesia and
hospitalization Services necessary to assure
the safe delivery of necessary dental care
provided to you or your Covered Dependent
in a Hospital or Ambulatory Surgical Center
a) the Covered Dependent is under 8
years of age and it is determined by a
dentist and the Covered Dependent's
Physician that:
I. dental treatment is necessary due to
a dental Condition that is
significantly complex; or
ii. the Covered Dependent has a
developmental disability in which
patient management in the dental
office has proven to be ineffective;
or
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.
1 . Dental Services provided more than 90 days
after the date of an Accidental Dental Injury
regardless of whether or not such services
could have been rendered within 90 days;
a-Fd
DIM MITTX@.Mr,,�� I i5 Jil�o =
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
ZTd
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
trex2lls, cims, c2lluses, 2rf fterapeuticirnWoes
(including inserts and/or modifications) for the
treatirent of severe diabetic foot disease.
Diagnostic Services
Diagnostic Services when ordered by a
Physician are limited to the following:
1. radiology, ultrasound and nuclear medicine,
Magnetic Resonance Imaging (MRI);
2. laboratory and pathology Services;
What Is covered? 15
3. Services involving bones or joints of the jaw
(e.g., Services to treat temporomandibular
joint [TMJ] dysfunction) or facial region
under accepted medical standards, such
diagnostic Services are necessary to treat
Conditions caused by congenital or
developmental deformity, disease, or injury;
4. approved machine testing (e.g.,
electrocardiogram
electroencephalograph [EEG), and other
electronic diagnostic medical procedures);
and
5. genetic testing for the purposes of
explaining current signs and symptoms of a
possible hereditary disease.
71MVT4MFrt=
and medical supplies, when provided at any
location by a Provider licensed to perform
A!1I .11 . - - -
F9M77T--T'rTTM
15F051117711117, 1 91,118111 - 1 6 1 a - 4 6 - -
11117T."LVA'T" 7AURAVVIV.1 - -
prescribed by a Physician, limited to the most
cost-effective equipment as determined by
BCBSF or Monroe County BOCC is covered.
Supplies and service to repair medical
eAuipmext m2y te Orveret Sexjices-zxly if yJ
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 pric% 42) the
Allowed Amount. The Allowed Amount for sucil
rental equipment will not exceed the total
purchase price. Durable Medical Equipment
includes, but is not limited to, the following:
ft-crutches-Qi=
beds, and oxygen equipment.
Note: Repair or replacement of Durable
significant change in functional status is a
Covered Service.
Equipment which is primarily for convenience
and/or comfort; modifications to motor vehicle
and/or homes, including but not limited to,
WMZ1Sh21r-rft
such as Jacuzzis, hot tubs, swimming pools or
whirlpools; exercise and massage equipment,
electric scooters, hearing aids, air conditioners
ers and/
purifiers, pillows, mattresses or waterbeds,
escalators, elevators, stair glides, emergency
alert equipt, hild grab bars, heat
aislia-f as, gehumidifiers. and the replaceme
is old or used are excluded.
Emergency Services
i FIVSFA. ■— s. T50
Condition are covered when rendered In -
Network and Out -of -Network without the need
When Emergency Services and care for an
an Out -of -Network Provider, any Copayment
and/or Coinsurance amount applicable to In -
also apply to such Out -of -Network Provider.
plans apply a specific method for determining
the allowed amount for Emergency Services
or determining
y Ser ices
n c VJ
rendered for an Emergency Me6dical Condition
What Is Covered? 26
that Provider vAll be the greater of:
1. the amount equal to the median amount
negotiated with all BCBSF In -Network
Providers for the same Services;
2. the Allowed Amount as defined in th
Booklet; or
3. what Medicare would have paid for
Sei4ces rendered.
rendered.
Enteral Formulas
Prescription and non-prescription enteral
formulas for home use when prescribed by a
Physician as necessary to treat inherited
diseases of amino acid, organic acid,
carbohydrate or fat metabolism as well as
malabsorption originating from congenital
1,0=4r,Xf
neonatal period are covered.
I - - . L __
sdd_����n to�vur �25th
birthday, shall include coverage for food
products modified to be low protein.
3=
ME=
namm=
cataract surgery-, and
irauma or prior ophthalmic surgery; eye
examinations; eye exercises or visual training;
CjjC1=A%AUUWU. III 43UUILIWII WUt�_WWj -1jr
if C 7Tn7;nj=.1
tr improve myopia or other refractive disordersO
(e.g., radial keratotomy, PRK and LASIK) are
eycluded. I
Home Health Care
The Home Health Care Services listed below
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
FE, the Home Health Care Services rendered
have been prescribed by a Physician by
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 b
required to provide a copy of any written
treatment plan; I
C 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
Totes.
Home Health Care Services are limited to:
1 . part-time (i.e., less than 8 hours per day a
less than a total of 40 hours in a calendar
week) or intermittent (i.e., a visit of up to, b
not exceeding, 2 hours per day) nursing
care by a Registered Nurse, Licensed
Practical Nurse and/or home health aide
Services; I
What Is Covered? 2-7
the • of a Registered Nurse;
3. medical social services:
■
6. respiratory, or inhalation therapy (e.g.,
■ and
6, Physical Therapy by a Physical Therapist,
• Therapy by a Occupational
Therapist, and Speech Therapy by a
Speech Therapist.
Exclusions:
1. homemaker or domestic maid services;
0
3. Services rendered by an employee or
operator of an adult congregate living
facility; an adult foster home; an adult day
care center, or a nursing home facility;
4. Speech Therapy provided for a diagnosis of
developmental ■
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;
asd
7. Services rendered in a Hospital, nursin-1
home, or intermediate care facility.
Hospice Services
Health Care Services provided in connection
with a Hospice treatment program may be
Covered Services, provided the Hospice
treatment program
1, approved by your Physician-, and
2. your doctor has ■ ■ us in writing that
your life expectancy Is 12 months or less.
Recertification is required every six months,
Hospital Services
Covered Hospital Services include:
1, room and board in a semi -private room
when ■ as an inpatient, unless the
patient must be isolated from others for
documented clinical reasons;
2. intensive care units, Including cardiac,
progressive and neonatal care;
33=
5. respiratory, pulmonary, or inhalation -•
(e.g., oxygen);
6. drugs and medicines ■ (except
for take home drugs) by the Hospital;
7. intravenous solutions;
8. administration of, including the cost •...
whole blood or blood products except as
■ in the Drugs exclusion of the *What
Is Not Covered?" section);
9. dressings, including ordinary casts;
10. anesthetics and their administration;
11. transfusion supplies and equipment,
12. diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG);
13. Physical, Speech, Occupational, and
Cardiac Therapies; and
14. transplants as described in the Transplant
Services subsection.
Exclusiom
excluded when such Services could have been
provided without admitting you to the Hospital:
1) room and board provided during the
were an inpatient; 3) Occupational Therapy,
v. Phvsical TheraDv. and Cardiac
What Is Cwmred? 24
Therapy; and 4) other Services provided while
you were an inpatient.
similar items are also excluded:
1. gowns and slippers;
2. shampoo, toothpaste, body lotions arl.
hygiene packets;
3. take-home drugs;
4. telephone and television;
5. guest meals or gourmet menus; ani
6. admission kits.
Inpatient Rehabilitation
Inpatient Rehabilitation Services are covered
when the following criteria are met:
Services must be provided under the
direction of a Physician and must be
accordance with a comprehensive
rehabilitation program;
a plan of care must be developed and
3. coverage is subject to our Medical Necessity
coverage criteria then in effect:
4. the individual must be able to actively
participate in at least 2 rehabilitative
therapies and be able to tolerate at least 3
hours per day of skilled Rehabilitation
Services for at least 5 days a week and their
Condition must be likely to result in
significant improvement; and
5. the Rehabilitation Services must be requirs
at such intensity, frequency and duration I
that further progress cannot be achieved irl
Inpatient Rehabilitation Services are subject to
the inpatient facility Copayment, if applicable,
and the benefit maximum set forth in the
pnm�
rM n r7i I F a I S -
T
excluded.
Mammograms obtained in a medical office,
medical treatment facility or through a health
agencies (or those of another state) for
Vnyr
are Covered Services.
— - & - I
the Deductible. Coinsurance, or Copayment (if
applicable). Please refer to your Schedule of
Benefits for more information.
Mastectomy Services
medical standards as determined by you and
your attending Physician are covered.
Outpatient post -surgical follow-up care for
Mastectomy Services shall be covered when
provided by a Provider in accordance with the
prevailing medical standards and at the most
medically appropriate setting. The setting may
be the Hospital, Physician's office, outpatient
center, or your home. The treating Physician,
after consultation with you, may choose the
appropriate setting.
Maternity Services
Health Care Services, including prenatal care,
telivery and postpartum care and assessmentm.
provided to you, by a Doctor of Medicine (M,D.),
Doctor of Osteopathy (D.O.), Hospital, Birth
be Covered Services. Care for the mother
includes the postpartum assessment.
What is Covered? 2-9
In order for the postpartum assessment to be
covered, such assessment must be provided a
a Hospital, an attending Physician's office, an
outpatient maternity center, or in the home by
qualified licensed health care professional
trained in care for a mother. Coverage under
this Booklet for the postpartum assessment
includes coverage for the physical assessmen
keeping with prevailing medical standards.
Under Federal law, your Group Plan generally
may not restrict benefits for any hospital lengt
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
mothers or newborn's attending Provider, afte
coTsultina with the mother. from dischaEging t
96 as applicable). In any case, under Federal
law, your Group Plan can only require that a
provider obtain authorization for prescribing a
dn' -. pwc
•
Maternity Services rendered to a Covered
3_ff"r_ADW
with, a Gestational Surrogacy Contract or
Arrangement are excluded. This exclusion
applies to all expenses for prenatal, intra-partal,
and post-partal Maternity/Obstetrical Care, and
Health Care Services rendered to the Covered
The Medical Pharmacy Cost Share amount
RIZIAnIOA11111111111 MD1 WVJ
L L&
for Medical Pharmacy, when such Services a
rv" e
ic
ar
Pharmacy. If your plan includes a Medical
Pharmacy out-of-pocket monthly maximum it
I "
will be listed on your Schedule of Benefits and
_uat�
lei _tt6t-V1tiJ'4re1
if applicable.
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
Medical Pharmacy.
Mental Health Services
Diagnostic evaluation, psychiatric treatment,
individual therapy, and group therapy rendere
to you by a Physician, Psychologist or Mental
and Nervous Disorder may be covered.
Covered Services may include:
1. Physician office visits',
2. Intensive Outpatient Treatment (rendered ir
a facility), as defined in this Booklet; and
Person acting as a Gestational Surrogate. Booklet, when provided under the directioF
Gestational Surrogacy Contract, see the
4DefinitionSh section of this Benefit Booklet.
Medical Pharmacy
Physician -administered Prescription Drugs
which are rendered in a Physician's office are
L Services rendered for a Condition that is in
a Mental and Nervous Disorder as defined
this Booklet, regardless of the underlying
cause, or effect, of the disorder-, i
2. Services for psychological testing
associated with the evaluation and diagnosis
What is Covered? 2.1u,
disability;
3. Services beyond the period necessary for
evaluation and diagnosis of learning
disabilities or intellectual disability;
5. Services for pre -marital counseling;
probation;
7. Services for testing of aptitude, ability,
intelligence or interest (except as coverev
under the Autism Spectrum Disorder
subsection);
8. Services for testing and evaluation foor the
purpose of maintaining employment;
9. Services for cognitive remediation;
'n
en
ft
r the
n
10. inpatient confinements that are pdnmarily
71
intended as a change of environment; or
11. innatient love * ht.1 mental hea Servic
fa
received in a residential treatment facility.
Newbom Care
A newborn child will be covered from the
is eligible for coverage and properly enrolled.
Covered Services shall consist of coverage for
injury or sickness, including the necessary care
or treatment of medically diagnosed congenital
Newborn Assessment:
717RINVITLEVrant FIVVLE
provided the Services were rendered at a
Center, or in the home by a Physician, Midwife
of any necessary clinical tests and
standards. These Services are not subject to
the Deductible.
Ambulance Services, when necessary to
.-iearest appropriate facility which is staffed andw
-.quipped to treat the newborn child's Conditio
as determined by BCBSF or Monroe Count I
BOCC and certified by the attending Physician
safety of the newborn child, are covered.
==7A
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 newbom 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
irLT.Q&ni -
211gag2jagg le , It
jjLrJJ!k-J_ "-le,
96 as applicable). In any case, under Federal
law, your Group Plan can only require that a
trthotic Devices including braces and trusses
for the leg, arm, neck and back, and special
a Physician and designed and fitted by an
Orthotist.
Benefits may be provided for necessary
replacement of an Orthotic Device which is
wear, a change in your Condon, 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-montJh
pedod unless a more frequent replacement is
to be Medically Necessary.
What Is Covered? 2"1 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-un stoes. cast shoes. sneakers, ready -
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 orthotic appliances or devices
which straighten or re -shape the
conformation of the head or bones of the
skull or cranium through cranial banding or
molding (e.g. dynamic orthotic cranioplasty
or molding helmets), except when the
orthotic appliance or device is used as an
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.
Screening, diagnosis, and treatment of
as medically necessary, including, but not
limited to:
1. estrogen -deficient individuals who are a)
clinical risk for osteoporosis;
ff. individuals who have vertebral
abnormalities;
3. individuals who are receiving long-term
glucocorticoid (steroid) therapy; or
4. indduals who have primary
hyperparathyroidism, and
5. individuals who have a family history of
osteoporosis.
Speech, Massage Therapies and Spinal
Manipulation Services I
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.
supervision of a Physician, or an appropriate
Provider trained for Cardiac Therapy, for the
purpose of aiding in the restoration of normal
heart function in connection with a myocardial
infarction, coronary occlusion or coronary
bypass surgery are covered.
Occupational Therapy Services provided by a
Physician or Occupational Therapist for the
purpose of aiding in the restoration of a
previously impaired function lost due to a
Condition are covered.
•- - F-URITIRF-11
Speech I herapist. or licensed auchologist wo
in the restoration of speech loss or an
are covered.
Physical Therapy Services provided by a
OrMITsTil Ma irs MoOfTir, Ii a
Massage Therapy Massage provided by a
Physician, Massage Therapist, or Physical
being Medically Necessary by a Physician
licensal ;"rsxant ts, F114fa Statytas ChaXW
458 (Medical Practice), Chapter 459
(Osteopathy), Chapter 460 (Chiropractic) or
Chapter 461 (Podiatry) is covered. The
Physician's prescription must specify the
number of treatments.
What Is Covered? 2,12.
Payment Guidelines for Massage and
Physical Therapy
1 . Payment for covered Massage Services is
limited to no more than four (4) 15-minute
Massage treatments per day, not to exceed
the Outpatient Cardiac, Occupational,
Physical, Speech, and Massage Therapies
and Spinal Manipulations benefit maximum
listed on the Schedule of Benefits.
2. Payment for a combination of covered
Massage and Physical Therapy Services
rendered on the same day is limited to no
more than four (4) 15-minute treatments per
day for combined Massage and Physical
Therapy treatment, not to exceed the
Outpatient Cardiac, Occupational, Physical,
Speech, and Massage Therapies and Spinal
Manipulations benefit maximum listed on thsn
Schedule of Benefits.
3. Payment for covered Physical Therapy
Services rendered on the same day as
spinal manipulation is limited to one (1)
Physical Therapy treatment per day not t-ir
exceed fifteen (115) minutes in length.
Spinal Manipulations: Services by Physicians
far maniXylatiins if the sAirie tz ca-wect a sli&Xt
dislocation of a bone or joint that is
demonstrated by x-ray are covered.
Payment Guidelines far jRfinal Manipulation,
limited to no more than 26 spinal
manipulations per Benefit Period, or the
2. Payment for covered Physical Therapy
Services rendered on the same day as a
spinal manipulation is limited to one (1)
Physical Therapy treatment per day, not to
exceed fifteen (115) minutes in length.
Your Schedule of Benefits sets forth the
WQYYnf0V(A& 'Mig&-m
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
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
ts jst� �ox em
are covered,
Physician Services
rendered in the Physician's office, in an
computer via the Internet.
Payment Guidelines for Physician Services
Provided by Electronic Means throunh a
CompiLter:
Expenses for online medical Services jprovVilde
via the Internet will be covered only if such
Services: I
were provided to a covered individual who
an established patient of the Physician
rendering the Services;
L were in response to an online inquiry
received through the Internet from the
covered individual with respect to which t1n;
Services were provided; and
3. were provided by a Physician through a
secure online healthcare communication
services vendor that, at the time the
Services were rendered, was under contract
V IT 11:101 *-1
The term 'established patient," as used herein,
shall mean that the covered individual has
What is Covered? 2-13
.eceived professional services from the
Physician who provided the online medical
Services, or another physician of the same
specialty who belongs to the same group
TITMT-17:1115,11-TOMT =tt -
via the Internet other than thro=ugh a healthcjar
skmwjn� P-A,
into contract with 13CBSF are excluded.
Expenses for online medical Services provide
bill a
Preventive Health Services
and children ] based on prevailing medical h
standards and re7commernidations which are
I
explained further below. Some examples of
preventive health Services include, but are not
limitel ti, Farislic r.xutixe ke2ftX ex2xxs, r-sutix.
preventive Services such as Prostate Specific
Antigen (PSA), routine mammagrarns and pap
smears. In order to be covered, Services shall
be provided in accordance with prevang
medical standards consistent vAth,
1 . evidence -based items or Services that have
in effect a rating of 'A' or 'B' in the current
recommendations of the U.S. Preventive
Services Task Force established under the
Public Health Service Act;
2. immunizations that have in effect a
recommendation from the Advisory
Committee an Immunization Practices of t
Centers for Disease Control and Preventi
established under the Public Health Servi -
Act with respect to the individual involved;1
c 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;
b. screening for gestational diabetes;
c. human papillornavirus testing;
d. counseling for sexually transmitted
infections;
e. counseling and screening for human
immune -deficiency virus;
f. contraceptive methods and counseling;
g. screening and counseling for
interpersonal and domestic violence;
and
h. breastfeeding support, supplies and
counseling. Breastfeeding supplies are
limited to one manual breast pump per
pregnancy.
Exclusion:
Routine vision and hearing examinations and
Services, except as required under paragraph
number one and/or number three above.
Sterilization procedures covered under this
category are limited to tubal ligations only.
Contraceptive implants are limited to Intra-
Medication Guide only, including insertion and
removal.
What Is Covered? 2-14
=10t
t7 -?Qkmw
T&O A 1kV2U-'VWW& Di
and fitted by a Prosthetist:
1 . artificial hands, arms, feet, legs and eyes,
including permanent implanted lenses
following cataract surgery, cardiac
pacemakers, and prosthetic devices incide
to a Mastectomy; I
2. appliances needed to effectively use artificial
limbs or corrective braces; or
LoIlla
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 child.
2. Expenses for cosmetic enhancements to
atilicial limbs.
rm- M mg W v Z", n
covered:
1 . Self -Ad ministered Prescription Drugs used
in the treatment of diabetes, cancer,
Conditions requiring immediate stabilization
(e.g. anaphylaxis), or in the administration of
dialysis; and
.iymbol in the Medication Guide when
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 ng/ml and one
abnormally low growth hormone
dependent pepfide or for Conditions of
growth hormone deficiency associated
with loss of pituitary function due to
trauma, surgery, tumors, radiation or
disease, or for state mandated use as in
patients with AIDS.
b. Continuation of growth hormone therapy
is only covered for Conditions
associated with significant growth
hormone deficiency when there is
evidence of continued responsiveness
to treatment. Treatment is considered
responsive in children less than 21
years of age, when the growth hormone
dependent peptide (IGF-1) is in the
normal range for age and Tanner
development stage; the growth velocity
is at least 2 cm per year, and studies
Treatment is considered responsive in
both adolescents with closed epiphyses
1 remains in the normal range for age
and gender.
Skilled Nursing Facilities
The following Health Care Services may be
Covered Services when you are an inpatient in a
Skilled Nursing Facility:
What Is Covered? 2-15
1. room and board;
E. respiratory, pulmonary, or inhalation therapy
(e.g., oxygen);
3. drugs and medicines administered while an
inpatient (except take home drugs);
4. intravenous solutions;
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);
• M=
8, diagnostic Services, including radiology,
ultrasound, laboratory, pathology and
approved machine testing (e.g., EKG);
9. chemotherapy treatment for prov
malignant disease; and I
10. Physical, Speech, and Occupational
Therapies.
required in order to determine coverage and
payment.
-'Ikuxrs�- M.
convalescent care, or any other Service
family members or the Provider are excluded.
Care ano
includes the following:
1. Health Care Services (inpatient and
outpatient or any combination thereof)
provided by a Physician, Psychologist or
Mental Health Professional in a program
accredited by the Joint Commission on the Iti
Accreditation of Healthcare Organiza ons
approved by the state of Florida (or anoth]
state) for Detoxification or Substance
Dependency.
2. Physician, Psychologist and Mental Heal
Professional outpatient visits for the car
and treatment of Substance Dependenc
Substance Dependency in a specialized
inpatient or residential facility or inpatient
25 2
change of environment are excluded.
Surgical Assistant Services
Services rendered by a Physician, Registered
Nurse First Assistant or Physician Assistant
intern, resident, or other staff physician is
available) when the assistant is necessary are
covered.
Surgical Procedures
may be covered including the following:
1. sterzation (tubal ligations and
vasectomies), regardless of Medical
Necessity',
2. surgery to correct deformity which was
caused by disease, trauma, birth defects,
growth defects or prior therapeutic
processes;
3. oral surgical procedures for excisions of
tumors, cysts, abscesses, and lesions of the
mouth;
4. surgical procedures involving bones or join
of the jaw (e.g., temporomandibular joint
[TMJI) and facial region if, under accepted
medical standards, such surgery is
necessary to treat Conditions caused by
congenital or developmental deformity, I
a
OEM - =.-
What is Covered? 2-16
the need for surgery; and
6. surgical procedures performed on a Covered
Plan ParUcipant. 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.
2. Surgical procedures for the treatment cIM
Morbid Obesity including: intestinal
bypass; stomach stapling; balloon
dilation and associated care for the
surgical treatment of Morbid Obesity,
the Covered Plan Participant has
previously undergone the same or
similar procedures in the lifetime of thi
Group Health Plan. Surgical procedur
performed to revise, or correct defects
related to, a prior intestinal bypass,
stomach stapling or balloon dilation ar
also excluded.
b. Reversal of a weight loss surgery,
surgical procedures to revise, correct,
and correction of defects to include
adjustment to devices implanted or any
fills not performed during the inal
surgical event.
Payment Guidelines for Surgical Procedures
1 . Payment for multiple surgical procedures
performed in addition to the primary surgical
procedure, on the same or different areas of
the body, during the same operative session
will be based on 50 percent of the Allowed
Amount for any secondary surgical
procedure(s) performed. In addition,
Coinsurance or Copayment (if any) indicate-te
in your Schedule of Benefits will apply. This
guideline is applicable to all bilateral
a
WrIFER-fiNi "01 41;4�hl W141-HR—w-
2. Payment for incidental surgical procedurcE
is limited to the Allowed Amount for the E
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
procedure which, in BCBSF's or Monroe
County BOCC's opinion, is not clearly
identified and/or does not add significant
no-paj re-fi
appendix in the example).
3. Payment for surgical procedures for fracture
care, dislocation treatment, debridement,
Health Care Services, is included in the
% I ical Drocedure
Transplant Services
W-TiTTIF51W�W Mi, Will
a facility acceptable to BCBSF ar.Monroe
County BOCC, subject to the conditions and
limitations described below.
Transplant includes pre -transplant, transplant
and post -discharge Services, and treatment of
yr� iation. Benefits wil'
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 59B-
12.001 of the Flotida Administrative Code or
M 7-D- U
published Medicare Coverage /ssues
What is Cove ? 2-17
provided for the expenses incurred for the
donation of bone marrow by a donor to the
same extent such expenses would be
covered for you and will be subject to the
applicable to you. Coverage for the
reasonable expenses of searching for the
donor will be limited to a search among
immediate family members and donors
TW-W,-XV13
Donor Program;
FJN•=�
3. heart transplant (including a ventricular
assist device, if indicated, when used as a
bridge to heart transplantation);
4. heart-lung combination transplant:
5. liver transplant;
6. kidney transplant:
7. pancreas;
8. pancreas transplant performed
simultaneously with a kidney transplant; or
9. lung -whole single or whole bilateral
transplant.
Coverage Ml be provided for donor costs and
irgan acquisition for transplants, other than
�—bn-o�son nother
than the donors family or estate.
You may call the customer service phone
number indicated in this Booklet or on your
i1afWiL,dft,raV1 41 yei• lz�zrm�-wN*
Bone Marrow Transplants are covered under
this Booklet.
What Is Covered? 2M
1. transplant procedures not included in the list
above, or otherwise excluded under this
Booklet (e.g., Experimental or Investigational
transplant procedures).
2. "Insplant procedures involving the
transplantation or implantation of any non-
human organ or tissue,
&VIT -7. 11 V 17174 0- 77� I
or acquisition of an organ or tissue for a
recipient who is not covered under this
Benefit Booklet;
- a 0
an artificial organ, Including the implant of t
artificial organ;
6. any Bone Marrow Transplant, as defined
herein, which is not specifically listed in rul�
598-112.001 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;
2. any non -medical costs, including but not
limited to, temporary lodging or transportation
costs for you and/or your family to and from
the approved facility; and
9. any artificial heart or mechanical device that
replaces either the atrium and/or the
ventricle.
What Is Covered? 2.19
Your Booklet expressly excludes expenses for
the following Health Care Services, supplies,
drugs or charges. The following exclusions are
in addition to any exclusions specified in the
cc� irt-romW-ithe"azim
of the Booklet.
TPTMJLT���_
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
regardless of intended use, except for
therapeutic shoes (including inserts and/or
modifications) for the treatment of severe
diabetic foot disease.
supplies, and medications for In Vitro
Fertilization (IVF); Gamete Intrafallopian
Transfer (GIFT) procedures; Zygote
Intrafallopian Transfer (ZIFT) procedures;
Artificial Insemination (AI); embryo transport;
surrogate parenting; donor semen and related
costs including collection and preparation; and
infertility treatment medication.
E■
I
unless specifically requested by BCBSF or
Monroe County BOCC.
•
271RE mUff —HUTT,
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', biofeedback; prayer and mental
healing; manual healing methods such as the
Alexander technique, aromatherapy, Ayurvedic
massage, craniosacral balancing, Feldenkrais
method, Hellerwork, polarity therapy, Reichian
therapy, reflexology, rolfing, shiatsu, traditional
Chinese massage, Trager therapy, trigger -point
myotherapy, and biofield therapeutics; Reiki,
SHEN therapy, and therapeutic touch;
41.ZL-
herbal therapies.
covered Health Care Service (e.g., Health Care
Services to treat a complication of cosmetic
surgery are not covered).
Contraceptive medications, devices,
- . - i' - iFlrjh Care Services when
provided for contraception, except when
indicated as covered, under the Preventive
Health Services category of the "What Is
Covered?" section.
Cosmetic Services, including any Service to
individual (except as covered under the Breast
without limitation: cosmetic surgery and
procedures or supplies to correct hair loss or
,skin wrinkling (e.g., Minoxidil, Rogaine, Retin-A),
and hair implants/transplants.
1
me q_71NiR1W M01611- 61 11_10=
of any form and/or medical information.
Custodial Care and any service of a custodial
ciature, including and without limitation: Health
What Is Not Covered? 3"1
af daily living; rest homes; home companions or
treatment of cancer that have not been
Atters; home parents; domestic maid services;
approved for any indication are excluded.
respite care; and provision of services which are
2. All drugs dispensed to, or purchased by, you
Tor the sole purposes of allowing a family
from a pharmacy. This exclusion does not
member or caregiver of a Covered Person to
apply to drugs dispensed to you when:
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,
AA A%,WbdonWLor_endod1ont1c procedures
orthodontic treatment (e.g., braces), intraoral
prosthetic devices, palatal expansion devices,
bruxism appliances, and dental x-rays. This
KUA _ffA1r%4_R.
AM
TMJ dysfunction. This exclusion does not apply
-ts�—
■
Lip and Cleft Palate Treatment Services
Srugs
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
you are an inpatient in a HosplfK,
Ambulatory Surgical Center, Skilled
Nursing Facility, Psychiatric Facility or
Hospice facility;
b. you are in the outpatient department of
a Hospital;
c. dispensed to your Physician for
administration to you in the Physicia
office and prior coverage authorizatii
has been obta(if required); andl
ined
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.
C. Any non -Prescription medicines, remedies,
vaccines, biological products (except
insulin), pharmaceuticals or chemical
compounds, vitamins, mineral supplements,
fluoride products, over-the-counter drugs,
products, or health foods, except as
described in the Preventive Health Services
category of the 'What Is Covered?" section.
4. Any drug which is indicated or used for
sexual dysfunction (e.g., Cialis, Levitra.
Viagra, Caverject). The exception described
in exclusion number one above does not
apply to sexual dysfunction drugs excluded
under this paragraph.
5. Any Self -Administered Prescription Drug not
indicated as covered in the "What Is
Covered?" section of this Benefit Booklet.
6. Blood or blood products used to treat
hemophilia, except when provided to you
for:
What Is Not Covered? 12
emergency stabilization;
b. during a covered inpatient stay, or
c. when proximately related to a surgical
procedure.
The exceptions to the exclusion for drugs
purchased or dispensed by a pharmacy
described in subparagraph number two do
not apply to hemophilia drugs excluded
under this subparagraph.
7. Drugs, which require prior coverage
authorization when prior coverage
authorization is not obtained.
S. Specialty Drugs used to increase height or
bone growth (e.g., growth hormone) except
for Conditions of growth hormone deficiency
documented with two abnormally low
stimulation tests of less than 10 ng/ml and
one abnormally low growth hormone
dependent peptide or for Conditions of
growth hormone deficiency associated with
loss of pituitary function due to trauma,
surgery, tumors, radiation or disease, or for
state mandated use as in patients with
AIDS,
■ A7717Y =bi '6771-
not be covered except for Conditions
deficiency when there is evidence of
continued responsiveness to treatment.
(See "What is Covered?" section for
addonal information.)
Experimental or Investigational Services,
except as otherwise covered under the Bone
Marrow Transplant provision of the Transplant
Services category.
I =.Of . Ito =444V =OUFN�Nl
91
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
coms, or calluses.
to:
1. any Health Care Service received prior to
your Effective Date or after the date your
coverage terminates;
2. any Service to diagnose or treat any
Condition resulting from or in connection
with your job or employment;
3. any Health Care Services not within the
service categories described in the 'What is
Covered?" section, any rider, or
Endorsement attached hereto, unless such
services are specifically required to be
covered by applicable law,
4. any Health Care 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;
7. expenses for claims denied because we did
not receive information requested from you
regarding whether or not you have other
coverage and the details of such coverage;
8. any Health Care Services to diagnose or
treat a Condon which, directly or indirectly,
resulted from or is in connection with:
2) 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 riot, or rebellion;
What is Not Covered? 3_�
c) your engaging in an illegal occupation;
d) Services received at military or
government facilities; or
e) Services received to treat a Condition
arising out of your service in the armed
forces, reserves and/or National Guard;
f) Services that are not patient -specific, as
determined solely by us.
9. Health Care Services rendered because
they were ordered by a court, unless such
Services are Covered Services under this
Benefit Booklet; and
10. any Health Care Services rendered by or
through a medical or dental department
maintained by or on behalf of an employer,
mutual association, labor union, trust, or
similar person or group; or
11. Health Care Services that are not direct,
hands-on, and patient specific, including, bj
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.
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
"WIrat Is Covered?" section.
Services MffM ;%Ts=f
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.
IVA ILOITT-�
v14K*1 i i N4 tj K=Ti I i M 11 IF mr- E=
M-1 rZ I
with, a Gestational Surrogacy Contract or
Arrangement. This exclusion applies to all
expenses for prenatal, intra-partal. and post-
partal Matemity/Obstetrical Care, and Health
acting as a Gestational Surrogate.
Gestational Surrogacy Contract see the
Deft����Wit• -
.WIrat Is Covered?" section.
47FL17.7&j-jT-r
vitamins, and food sup•lements.
oversight of a medical laboratory by a
Physician or other health care Provider.
�Oversight" as used in this exclusion shall,
d to. tLEe oversicLht•
1. the laboratory to assure timeliness,
reliability, and/or usefulness of test results;
2. the calibration of laboratory machines or
testing of laboratory equipment;
3. the preparation, review or updating of any
protocol or procedure created or reviewed
by a Physician or other health care Provider
in connection with the operation of the
laboratory; and
4. laboratory equipment or laboratory
personnel for any reason.
Necessary and not directly related to your
treatment including, but not limited to:
1. beauty and barber services;
2. clothing including support hose;
3. radio and television;
4. guest meals and accommodations;
5. telephone charges;
6. take-home supplies;
7. travel expenses (other than Medically
Necessary Ambulance Services);
8. motel/hotel accommodations;
What Is Not Covered? 3-4
air conditioners, furnaces, air filters, air or
water purification systems, water softening
systems, humidifiers, dehumidifiers, vacuum
cleaners or any other similar equipment and
devices used for environmental control or to
enhance an environmental setting;
10. hot tubs, Jacuzzis, heated spas, pools, or
memberships to health clubs;
12. physical fitness equipment;
13. hand rails and grab bars; and
overed in the 'What Is
Private Duty Nursing Care rendered at any
location-
s]
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.
Reversal of Voluntary, Surgically -Induced
Sterility including the reversal of tubal ligations
and vasectornies,
Sexual Reassignment or Modification
Services including, but not limited to, any Health
Care Services related to such treatment, such
as psychiatric Services.
sei z ice to
In, or addiction to, tobacco, including but not
limited to nicotine withdrawal programs and
nicotine products (e.g., gum, transdermal
patches, etc.).
Sports -Related devices and services used to
affect performance primarily in sports -related
activities; all expenses related to physical
bodybuilding, exercise, fitness, flexibility, and
diversion or general motivation.
Training and Educational Programs, or
materials, including, but not limited to programs
or materials for pain management and
vocational rehabilitation, except as provided
xnder the T,'ia!retes#YtAatient Self Management
category of the "What Is Covered?* section.
or ordered by a Provider.
Volunteer Services or Services which would
normally be provided free of charge and any
charges associated with >!eductible,
Coinsurance, or Copayment (if applicable)
Provider.
ding ss
7 'W7
to lose, gain, or maintain weight, including
I
without limitation: any weight control/loss
I
program; appetite suppressants; dietary
rc
regimens; food or food supplements; exercise]
TMUH-i--Aae-
a treatment plan for a Condon. i
What Is Not Covered? 3-5
MTMOrmr?i i C CT 1l 1. b I �2.0 C �Ll
T,nder this i5ooklet, sxch Services myst meet all
of the requirements to be a Covered Service,
by this Benefit Booklet.
It is important to remember that any review of
uaa= nf gedgirr Wig, nnigapi beyits, or
paimer[U-1
for the purpose of recommending or providing
medical care. In conducting a review of Medical
Necessibc BCBSF mav review snecific medical
facts or information pertaining to you. Any such
review, however, is strictly for the purpose of
determining whether a Health Care Service
provided or proposed meets the definition of
Medical Necessity in this Booklet. In applying
the definon of Medical Necessity in this
Booklet to a specific Health Care Service,
er=-� M4T�
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
M TA T 0
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 been
completed;
2. use of laboratory, x-ray, or other diagnostic
testing that has no clear indication, or is no)
expected to alter your treatment;
3. staying in the Hospital because supervision
in the home, or care in the home, is not
available or is inconvenient; or being
hospitalized for any Service which could
have been provided adequately in an
alternate setting (e.g., Hospital outpatient
department or at home with Home Health
Care Services); or
4. inpatient adMi55iOnS to a Hospital, Skilled
Nursing Facility, or any other facility for the
purpose of Custodial Care, convalescent
care, or any other Service primarily for the
convenience of the patient or his or her
family members or a Provider.
Note: Whether or not a Health Care Service
is s;recificzlly listed as ax exclusi"-, fte tct
that a Provider may prescribe, recommend,
approve, or furnish a Health Care Service
does not mean that the Service is Medically
Necessary (as defined by this Benefit
Booklet) or a Covered Service. Please refer
to the "Definitions" section for the
definitions of "Medically Necessary" or
"Medical Necessity".
Medical Necessity 4,1
Section 5: Understanding Your Share of Health Care
W =9
This section explains what your share of the
health care expenses will be for Covered
Services you receive. In addon to the
information explained in this section, it is
important that you refer to your Schedule of
regard to Covered Services.
I ITT— M4 fl
F"Mm- 311177111717M M-T-M
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
Sckedule of Benefits for more information.
rfmrrmmmian
If your plan includes a family Deductible, after
the family Deductible has been met by your
f your
e am
p
i
an inc U
y Deduc
de ti
s a
be I h
I ami y D t, as been
e I m du e
c
t
I ti b
b
yy0aft
ur
e'
amily, 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
Ann a
Please see your Schedule of Benefits for mar]
ilirformation.
AE5)1;�T. T
t
or at certain locations or settings will be subjec
to a Copayment requirement. This is the Idolla
Services. Please refer to your Schedule of
are subject to a Copayment. Listed below is a
brief description of some of the Copayment
requirements that may apply to your plan. If the
RWIEft-97 =-0 Vfq V1 I 91A ZA A 14 "Mut
the Allowed Amount or the Providers actual
charge for the Covered Service.
if your plan is a Copayment plan, the
in the office (when applicable) must be
satisfied by you, for each office Service
before any payment will be made. The
office Services Copayment applies
regardless of the reason for the office visit
and applies to all Covered Services
Durable Medical Equipment, Medical
Pharmacy, Prosthetics, and Orthotics.
Generally, if more than one Covered Service
that is subject to a Copayment is rendered
during the same office visit, you will be
responsible for a single Copayment which
will not exceed the highest Copayment
specified in the Schedule of Benefits for the
particular Health Care Services rendered.
PM =I. - M 17 1; r R n $TL@ZZ=
The inpatient facility Copayment must be
satisfied by you, for each inpatient
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
Understanding Your Share of Health Care Expenses 5-11
r 1,11 11 -litit"N
of -pocket expenses for Covered Services
provided by Physicians and other health
Note: Inpatient facility Copayments may
vary depending on the facility chosen.
(Please see the Schedule of Benefits for
more information).
iMs
SEEM M-W 7
Hospital, Ambulatory Surgical Center,
Independent Diagnostic Testing Facility,
Psychiatric Facility or Substance Abuse
any claim for outpatient Covered Services.
The Outpatient Facility Copayment applies
regardless of the reason for the visit, and
applies to all outpatient visits to a Hospital,
Psychiatric Facility or Substance Abuse
Facility in or outside the state of Florida.
A-1tithmially, yz�: will ke res;rzAsikle fir vut-
of-pocket expenses for Covered Services
professionals.
Note: Outpatient facility Copayments m
vary depending on the facility chosen.
(Please see the Schedule of Benefits for
more information).
amount, and applies to emergency room
facility Services in or outside the state of
Florida. The emergency room 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
facility Copayment will be waived, but you
facility Copayment.
The Hospital Per Admission Deductible (PAD)
must be satisfied by each Covered Plan
Participant, for each Hospital admission, before
any payment will be made for any claim for
inpatient Health Care Services. The Hospital
Per Admission Deductible applies regardless of
iMothe
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
time of the emergency room visit, the
Emergency Room Per Visit Deductible will be
walved.
M
- a FITAM��
must be satisfied before any portion of the
Allowed Amount will be paid for Covered
Services. For Services that are subject to
applicable Allowed Amount you are responsible
for is listed in the Schedule of Benefits.
Individual out-of-pocket maximum
Once you have reached the individual out -of -
Undemanding Your Share of Health Care Expenses C-2
roll --=I - 11 4 , art R([&jjTfl 0 a 4
Mein Fenca SHE we 1151 #1
the Allowed Amount for Covered Services
- Q
Family out-of-pocket maximum
If your plan includes a family out-of-pocket
maximum, once your family has reached the
,amily out-of-pocket maximum amount listed in
the Schedule of Benefits, neither you nor your
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
Tut -If -
pocket maximum. Please see your Schedule of
BeTefts for more information.
Note* The Deductible, PAD, PTD, any
2pplicable Copayments and Coinsurance
amounts will accumulate toward the out-of-
pocket maximums. Any benefit penalty
rtikiL,*tknfb-,-t-KA-i=csiware-I Giwdy-jes xi,-�,Srges
in excess of the Allowed Amount will not
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
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,
was
in effect immediately preceding the Effective
irr
Booklet. This provision is only applicable for y
during the initial Benefit Period of coverage
under this Benefit Booklet and the following
rules apply: I
For the initial Benefit Period of coverage
under this Benefit Booklet only, charges
credited towards your Deductible
-RUFT 1117M��
L rRui-TAFUIR19TIT.-A
Date of the coverage under this Benefit
requirement under this Booklet.
910z� =ENUMK-1��
Charges credited by Monroe County
BOCC's prior policy or plan, towards your
Coinsurance Maximum, for Services
rendered during the 90-day period
n-!W-e-1WVW
credited to your out-of-pocket maximum
under this Booklet.
C Prior coverage credit towards the Deductiblz
or out-of-pocket maximums will only be
given for Health Care Services which would
have been Covered Services under this
Booklet.
Prior coverage credit under this Booklet only
applies at the initial enrollment of the entire
Group. You and/or Monroe County BOCC
are responsible for providing BCBSF with
any informaflon necessary for BCBSF to
apply this prior coverage credit.
LILI•111
covered under a prior Monroe County BOCC
understanding Your Share of Health Care Expenses 5.1
MEMEOMEMEEMMM321 M_ M - =.- -
In addition to your share of the expenses
e. vou are a so resoonsible for:
2. expenses incurred for non -covered
Services;
3. charges in excess of any maximum benefit
limitation listed in the Schedule of Benefits
(e.g., the Benefit Period maximums);
4. charges in excess of the Allowed Amount for
Covered Services rendered by Providers
who have not agreed to accept the Allowed
Amount as payment in full;
5, any benefit reductions;
6. payment of expenses for claims denied
because we did not receive information
requested from you regarding whether or not
you have other coverage and the details of
such coverage; and
7, charges for Health Care Services which are
excluded.
Additionally, you are responsible for any
BOCC,
Credited
ftly amounts actually paid for Covered
aenefit maximums. The amounts paid which a
based on the Allowed Amount for the Covered
Services provided.
Understanding Your Share of Health Care Expenses 54
Section 6: Physicians, Hospitals and Other Provider
It is important for you to understand how the
iT
you are responsible for paying under this
Booklet. This section, along with the Schedule
of Benefits, describes the health care Provider
options available to you and the payment rules
for Services you receive.
As used throughout this section "out -of -pock
expenses" or 'out-of-pocket" refers to the
CoiTsuraT.ce 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
err�'ET IT.iTr Tito i I 'Wr TITAT I
TrI
conformity with Section 7: BlueCard (Out -of -
State) Program.
Covered Services by receiving care from an In
Network Provider, Although you have the opti
to select any Provider you choose, you are
0
t u
m
a
e
r
a n op
In
t!
e
with an In -Network Family Physician. There a
several advantages to selecting a Family
Physician. Family Physicians are trained to
provide a broad range of medical care and ca
be a valuable resource to coordinate your
overall healthcare needs. Developing and
i ' �Clyewr
21lows the physician to become knowledgeablel
about you and your family's health history. A
Family Physician can help you determine whe
you need to visit a specialist and also help you
•
find one based on their knowledge of you and
your specific healthcare needs. Types of Fami
Physicians are Family Practitioners, General
Practitioners, Internal Medicine doctors and
Pediatricians. Additionally, care rendered by
q1VVWFfi k9w- - - — lwt-
pocket expenses for you. Whether you select -
Family Physician ir anither tyXe Tf Physician
render Health Care Services, please remembe
that using In -Network Providers may result in
lower out-of-pocket expenses for you. You
should always determine whether a Provider i
In -Network or Out -of -Network prior to receivin
Services to determine the amount you are
responsible for paying out-of-pocket.
In addition to the participation status of the
Provider, the location or setting where you
FRUR MIMI!"
paying out-of-pocket W11 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 also
consult with your Physician to determine the
most appropriate setting based on your health
care aiDd financial needs.
Physicians, Hospitals and Other Provider Options i
To verify if a Provider is In -Network
for your plan you can:
1. If in Florida, review your current BlueOpticli
Provider Directory;
3. If outside of Florida, access the on-line
BlueCard Doctor and Hospital Finder at
www,floddablue.com and/or
T_r 74 111 ff-A I �, M.
Consequently, it is your responsibility to
lei
When you use In -Network Providers, your out-
of-pocket expenses for Covered Services may
be lower. Payment will be based on the Allowed
When you use Out -of -Network Providers your
out-of-pocket expenses for Covered Services
will be higher. We will base our payment on t
listed in the Schedule of Benefits. Further, if t
Out -of -Network Provider is a Traditional
N
r e
e
0
C n
0 0
u
a T
v
r
r
P
e
s
a r
p
0 e
a
d
v d
F
it
io
d S u
n
e
e
e
a
r h
n
s 1 Ir e ry rt t y i r
c 0
0 e n
u
i
5
t r
f t
Program Provider or a BlueCard (Out -of -State
Traditional Program Provider, our payment to
such Provider may be under the terms of that
Providers contract. If your Schedule of Bene
and BlueCiptions Provider directory do not
include a Provider as In -Network under your
Physicians, Hospitals and Other Provider Options
I III �� III jjri�p III
17-1
Out-o two MINE
- -----------
What expenses
are you
responsible for
paying?
Who is
responsible for
filing your
claims?
t--l1L or -All I I
Can you be billed
YES. You are responsible for paying
the difference
the difference between what we pay
between what the
and the Provider's charge. However,
Provider Is paid
if you receive Services from a
and the Providees
Provider who participates in our
charge?
Traditional Program, the Provider will
accept our Allowed Amount as
payment in full for Covered Services
since such Traditional Program
Providers have agreed not to bill you
for the difference. Further, under the
BlueCard (Out -of -State) Program,
when you receive Covered Services
from a BlueCard (Out -of -State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's. billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is I n-Network or Out -of -Network. You are also responsible for determinin,f
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians, Hospitals and Other Provider Options r�--3
AY=
L !4A a - - yeluivi
Physician you will be responsible for a
Copayment and/or the Deductible and the
your Schedule of Benefits, whether the
Physician is In -Network or Out -of -Network, the
tm�� red. rv���ice �rende�
and the Physician's specialty.
Itemember 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 Services.
Each time you receive inpatient or outpatient
Covered Services at a Hospital, in addition to
Services, you will be responsible for out-of-
pocket expenses related to Hospital Services,,
groups that are referred to as 'options" on the
Schedule of Benefits. The amount you are
are also different out-of-pocket expenses for
Out -of -Network 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.
Refer
the applicable out-of-pocket expenses you are
responsible for paying for Hospital Services.
P77TUIM "SLIja =-,
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
to preserve your benefits.
described in this section. Other Providers
include faces that provide alternative
tutpatient settings or other persons and entities
ihat specialize in a specc Service(s). While
1hey 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
ftis Booklet. Please refer to the
ka-TIT.
Physicians. Hospitals and Other Provider Options 64
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 afternative 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
most appropriaTe-Yoff your care, y0j. 5n0j. u
to the Schedule of Benefits and consult with
your Physician to determine the most
appropriate setting based on your health care
and financial needs. When Services are
rendered at an outpatient facility other than a
HirsXital there may ie an z�!t0-4acket ex�wse
for the facility Provider as well as an out-of-
pocket expense for other types of Providers.
section, any of the following assignments, or
will not be honored:
an assignment of the benefits due to you for
Covered Services under this Benefit
Booklet;
an assignment of your right to receive
payments for Covered Services under thiip
Benefit Booklet; or
IN an assignment of a claim for damage
resulting from a breach, or an alleged
breach of the terms of this Benefit Bookil
We specifically reserve the right to honor an
assignment of benefits or payment by you to a
Provider who: 1) is In -Network under your plan
nf Mny 0: 21 is a
U1,11711119 =&SrTam [Me "I U -
I
BlueCard (out -of -State) PPO Program
Provider; 5) is a BlueCard (Out -of -State)
Traditional Program Provider, 6) is a licensed
Hospital, Physician, or dentist and the benefits
or 7) is an Ambulance Provider that provides
transportation for Services from the location
where an "emergency medical condition",
defined in section 395.002(8) Florida Statutes,
first occurred to a Hospital, and the benefits
to care provided pursuant to section 395.1041,
Florida Statutes. A written attestation of the
assignment of benefits may be required.
PhysIdens, Hospitals and Other Provider Options M
We have a variety of relationships with other
Blue Cross and/or Blue Shield Licensees
referred to generally as "Inter -Plan Programs".
Whenever you obtain Health Care Services
we ",,a cthwf-a fir-tieaa
Services may be processed • one of
these Inter -Plan Programs, which include the
■ Account arrangements available
between us and other Blue Cross and Blue
Typically, when accessing care outside our
service area, you will obtain care from health
care Providers that have a contractual
agreementare "participating providers")
with the local Blue Cross and/or Blue Shield
Licensee in that other geographic area CHost
from non -participating health care Providers.
Our payment practices in !• 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 ■ Blue is
responsible for contracting with and generally
handling all interactions with its participating
=M�M
Whenever • access Covered Services
outside our service area and the claim is
amount you pay for Covered Services is
calculated based on the lower of.
0 The billed covered charges for your
"A7MTJT1=_ Iva j;
makes available to us. I
Often, this 'negotiated price" will be a simple
Blue pays to your health care Provider.
�'�tialtAake&jnto_
account special arrangements vAth 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 • 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
Toted above. Vwww4er.
for your claim because they will not be applied
retroactively to claims already paid.
•r ■
If any state laws ■
_ other liability
calculation methods, including a surcharge, we
Services according to applicable law.
Service Area
Your Liability Calculation
Providers, the payment will be based on the
Allowed Amount as defined in the Benefit
BaoWet.
Slu&Card (Cut-of-Stata) Program 1-1
I =I. M=
BCBSF has established (and from time to time
establishes) various customer -focused health
education and information programs as well as
benefit utilization management and utilization
review programs. Under the terms of the ASO
Agreement between BCBSF and Monroe
County BOCC, BCBSF has agreed to make
these programs available to you. These
programs, collectively called the Blueprint for
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
usz
Facility or Skilled Nursing Facility which is In -
Network or Out -of -Network.
Under the admission notification requirement,
we must be notified of all inpatient admissions
L . elective ned urgent or emerg-micg) to
In -Network Hospitals, Psychiatric Facilities,
Substance Abuse Facilities or Skilled Nursing
Facilities, While it is the sole responsibility of
the In -Network Provider located in Florida to
comply with our admission notification
requirements, you should ask the Hospital,
."SyChiatni:7- I I Y, U s ce
�-!*illed Nursing Facility (as applicable) if we
3ave been noed of your admission. For an
�_dmission outside of Florida, you or the
Hospital, Psychiatric Facility, Substance Abuse
j'
should notTify us of t=admisslon. Making�ssur T
0 V U. iol
for Health Programs available to you. You or
y
the Hospital, Psychiatric Facility, Substance i
Abuse Facility or Skilled Nursing Facility (as
applicable) may notify us of your admission by
calling the toll free customer service number o
your ID card.
Skilled Nursing Facility, you or the Hospital,
PSYChW6_t_.
Skilled Nursing Facility should notify BCBSF o r t I
he Hos
I notify BC
pit
a
BS
"17
;;Oto 8 4
.S
the admission. Notifying BCBSF of your
admission will enable BCBSF to provide you
information about the Blueprint for Health
Programs available to you. You or the Hospit
may notify BCBSF of your admission by callin NOW WIM- M � Ilk-4kiriTol it
Under the inpatient facility program, we may
-eview Hospital stays, Hospice, Inpatient
�re Se�rvices
-endered during the course of an inpatient stay
ir treatment program. We may conduct this
7 iew while you are inpatient, after your .ev
Ascharge, or as part of a review of an episode
Blueprint for Heafth Programs _l
• 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 • 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
facts or • and assess, among other
■ 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 b i us I and an A reviews or assessments
MR
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.
Certain NetworkBlue Providers have agreed to
participate in our focused •
management program. This pre -service reviev
program is intended ■ promote the efficient
delivery of medically appropriate Health Care
Services by NetworkBlue Providers. Under thii
program we may perform focused prospective
reviews of all or specific Health Care Services
proposed for you. In order to perform the
Care Services proposed for you. These
NetworkBlue Providers have agreed not to bill,
ar eflect, any Xayrnant whatsitever frim yxw -t
"-' fil�-
a specific Health Care Service it
for a focused prospective review when
required under the terms of their agreement
with us; or
2. we perform a focused review under the
focused utilization management program
and we determine that a Health Care
Service is not Medically Necessary in
accordance with our Medical Necessity
criteria or inconsistent with our benefit
guidelines then in effect unless the following
exception applies.
1, : - . IRr
OR
determined to be not Medically Necessary by
BCBSF under this focused utzation
Tai
they give you a written estimate • your
financial obligation • the Service;
be Medically Necessary; and
c. you agree • assume financial responsibility
for such Service.
It is important for you to understand our prior
coverage authorization programs and how the
receive affects these requirements and
ultimately how much you are responsible for
paying under this Benefit Booklet.
I A • . ■T■- T- - #Lk� _ .■ _ . .
prior coverage authorization from us for:
1. advanced diagnostic Imaging Services,
such as CT scans, MRIs, MRA and nuclear
imaging;
Blueprint for Health Programs 84
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
authodzation program or a pre -service
notification program as defined and
administered by us,
IM A019111A te; L. I-
an In -Network Provider or an Out -of -Network
In -Network Providers
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
duuaF[aertWxrrtvr,rthe
the information and make a prior coverage
ecisio-f. based an our established
In the case of advanced diagnostic
Imaging Services such as CT scans, MRIs,
MRA and nuclear imaging, it is your sole
responsibility to comply with our prior
coverage authorization requirements when
rendered or referred by an Out -of -Network
Provider before the advanced diagnostic
imaging Services are provided. Your
failure to obtain prior coverage
authorization will result In denial of
coverage for such Services.
I .a
coverage authorization for advanced
customer service phone number on the back
of your ID 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
Se■
3. In the case of other Health Care Services
under a prior coverage authorization or pre -
service notification program, it is your sole
responsibility to comply with our prior
coverage authorization or pre -service
notification requirements when rendered or
referred by an Out -of -Network Provider,
before the Services are provided. Failure
to obtain prior coverage authorization or
provide pre -service notification may
result In denial of the claim or application
of a financial penalty assessed at the
time the claim is presented for payment
to us. The penalty applied will be the lesser
of $500 or 20% of the total Allowed Amount
of the claim. The decision to apply a penalty
or deny the claim will be made uniformly and
will be identified in the notice describing the
prior coverage authorization and pre -service
nlr-m...
a— t- FU JMKI
been received from you and/or the Out -of -
Network Provider, BCBSF or a designated
vendor, will review the information and make a
our established criteria then in effect. You will
be notified of the prior coverage authorization
decisioT.
Blueprint for Heafth Program' a-3
if -Network Health Care Service subject to a
prior coverage authorization or pre -service
notification program, including how you can
obtain prior coverage authoriization and/or
provide the pre -service nocation for such
Service not already listed here. This informati
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
i ArITLIBASTJ
'!MU
See the "Claims Processing" section for
authorization is denied.
Note: Prior coverage authorization is not
for the treatment of an Emergency Medical
Condon.
The Bluepdnt for Health Programs may includ
voluntary programs for certain members. The
programs may address health promotion,
prevention and early detection of disease,
chronic illness management programs, case
management programs and other member
focused programs. I
Personal Case Management Program
The personal case management program
focuses on members who suffer from a
catastrophic illness or injury. In the event you
may, in BCBSF's sole discretion, assign a
Personal Case Manager to you to help
. �ta A -- ----men for
Health Care Services you receive. Your
VUO
you may be offered alternative benefits or
:riade available on a case -by -case basis when
;iou meet BCBSF's case management criteria
ihen in effect. Such alternative benefits or
payments, if any, will be made available in
accordance with a treatment plan with which
�Ar �our re:Eresentative and Nour Ph�isician
agree to in writing. In addition, Monroe County
BOCC vAll be required to specifically agree to
or payment.
the personal case management program have
way obligates 3CBSF, Monroe County BOCC,
or the Group Health Plan to continue to provid
1�--X als-f I 7JAZC 9madsr-e- - - ---
contained in this section shall be deemed a
waiver of Monroe County BOCC's right to
terms. The terms of this Booklet will continue
apply, except as specifically modified in writin
in accordance with the personal case
management program rules then in effect.
Health Information, Promotion, Prevention
and Illness Management Programs
These Blueprint for Health Programs may
include health information that supports health
care education and choices for healthcare
issues. These programs focus on keeping you
well, help to identify early preventive measures
of treatment and help covered individuals with
chronic problems to enjoy lives that are as
productive and healthy as possible. These
programs may include prenatal educational
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 I D card for
more information. Your particioation in this
program is completely voluntary.
Blueprint for Heafth Pmgrams 0,4
BCBSF'S BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain to
Independent professional medical/clinical
judgment or training, or the need for medical
services, are solely your responsibility and the
responsibility of your Physicians and other
health care Providers. You and your Physicians
are responsible for deciding what medical care
should be rendered or received, and when and
how that care should be provided. Monroe
County BOCC is ultimately responsible for
determining whether expenses, which have
i-ze%a rdwr;a. f kA lro
will be, covered under this Booklet. In fulfilling
this responsibility, neither BCBSF nor Monroe
ke gaema"
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.
8tuepint for HeaKh Pmgramm 13-5
I I a a -
io participate in the Monroe County Group
Health Plan, and who meets and continues to
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
Plan Participants
Plan Participant, an individual must be an
Eligible Employee or Eligible Retiree. An
Eligible Employee must meet each of the
f lollowing requirements:
1. The employee must be a bona fide
employee of a Monroe County Employer,
participating in the Monroe County Group
Health Plan;
NEW MI, ME I, r4TJkTRIWr7ITI-11W[==, 0
ME=
4. The employee must meet any additional
eligibility requirement(s) required by Monroe
County BOCC.
3-MR-Um
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;
4. employees of affiliated or subsidiary
companies of Monroe County BOCC; and
5. other individuals as determined by Monroe
County BOCC.
Tft.6
concerning the expansion of eligibility
classifications.
- # - 1 4 1" , - - - -
lependent(s)
An individual who meets the eligibility criteria
specified below is an Eligible Dependent and is
eligible to apply for coverage under this Booklet:
Covered Plan Participant's spouse
under a legally valid existing marriage under
Federal Law.
2. The Covered Plan Participant's natural,
newbom, adopted, Faster, or step child(ren)
(or a child for whom the Covered Plan
Participant has been court -appointed as
legal guardian or legal custodian) who has
rtot reacted the end of the Calendar Year ift_
which he or she reaches age 26 (or in the
case of a Foster Child, is no longer eligible
under the Foster Child Program), regardless
of the dependent child's student or marital
status, financial dependency on the Covered
Plan Participant, whether the dependent
child resides with the Covered Plan
Participant, or whether the dependent child
Eligibliky For Coverage 9.1
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 end of the Calendar Year in which
he or she becomes 26 obtains a dependent of
their own (e.g., through birth or adoption) such
newborn child will not be eligible for this
also lose his or her eligibility for this coverage. It
is the Covered Plan Participant's sale
applicable requirements for eligibility.
917m- Ilic4thiffilt-irg M., arzammam
n
reaches age 26.
Children
A Covered Dependent child may continue
riln
1. unmarried and does not have a dependent',
2. a Florida resident or a full-time or part-time
student;
C. not enrolled in any other health covera
policy or group health plan, and I
not entitled to benefits under Title XVIII of
the Social Security Act unless the child is a
handicapped dependent child.
1917m- 111-7--y-Tillin M,
F
reaches age 30.
Handicapped Children
1 11 � I �.- a IFTITO I 10f;1 01 OW 1115, M=1 - M
Covered Dependent, beyond the age of 26, if
tke child is:
1, otherwise eligible for coverage under the
Group Health Plan;
Er. incapable of self-sustaining employment by
reason of mental retardation or physia
handicap; and
3. chiefly dependent upon the Covered Plan
Participant for support and maintenance
provided that the symptoms or causes of the
child's handicap existed prior to the child's
26�h birthday.
the month in which the dependent child no
longer meets the requirements for extended
eligibility as a handicapped child.
Exception for Students on Medical Leave of
Absence from School
A Covered Dependent child who is a full-time or
part-time student at an accredited post-
ondary institution, who takes a physician
certified medically necessary leave of absence
�e UZI ;Iaref Wvi6la
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
Ellgibilly For Coverage S-2
!'' ITRIM -mere III
2ccording to the provisions below.
Any Eligible Employee, Eligible Retiree or
Eligible Dependent who is not properly enrolle
will not be covered under this Benefit Booklet
Neither BCBSF nor Monroe County BOCC will
who is not properly enrolled.
Any Employee, Eligible Retiree, or Eligible
Dependent who is eligible for coverage under
the provisions set forth below.
14M �1- I I = :4 M Mr. . =
1. complete and submit, through Monroz
County BOCC Benefits Office, the
Enrollment Form;
L provide any additional information needed
determine eligibility, at the request of
BCBSF or Monroe County BOCC Benefits
Office; I
77-ff IT, ON=
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:
Employee Only Coverage - This type i
coverage provides coverage for the
Employee/Retiree only. I
coverage provides coverage for the
under a legally valid existing marriage under
Federal Law or Domestic Partner.
Zoverage provides coverage for the
Employee/Retiree and the covered child(renj
inly.
Employee/Family Coverage - This type of
coverage provides coverage for the
for each Covered Dependent based on the
14.o.Troe Countv BOCC.
#M1
are as follows:
Initial Enrollment Period is the period of time
during which an Eligible Employee or Eligible
Dependent is first eligible to enroll. It starts on
At, I K.M961ATATYA
days later.
R time OTI-Ing i1nicri U-Sul M191610
7'T ir
rrr r.'r-"M
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
Eligible Employee or Eligible Dependent may
apply for coverage. Special circumstances are
described in the Special Enrollment Period
subsection.
Enrollment and EffectIve Date at Coverage loll
:r-11M. =Zni n. MM
,y.Mlv a -troll u-rdoklet
Special Enrollment Period. The Effective Date
will be the date specified by Monroe County
BOCC.
I 1=, I 1 11 - I
al
Eligible Dependent of a Covered Plan
Participant. Below are special rules for certain
Eligible Dependents.
A
is an Eligible Dependent, the Covered Plan
Participant must submit an Enrollment Form, lt�o
Office during the 30-day period immediately
following the date of birth. The Effective Date
coverage for a newborn child will be the date
bi-tY.
MV [NAIM 1161r-101411110
ILL.
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
Enrollment event, during the Special Enrollment
Period.
Aote: For a Covered Dependent child who has
:eached the end of the Calendar Year in which
'-ie or she becomes 26 and the Covered
Dependent child obtains a dependent of their
twn (e.g,, through birth or adoption), such
newborn child will not be eligible for this
coverage and cannot enroll. Further, such
Covered Dependent child will also lose his or
her eligibility for this coverage.
Adopted Newbom 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
coverage for an adopted newborn child, eligible
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
documents that are deemed necessary in order
to administer this provision.
If timely notice is given, no additional
contribution will be charged for coverage of the
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
;,IF yuW-rkh-ii1e. L-iYU " �" -36f dkv4va
initial 30-day period in either case. Coverage
will not be denied for an adopted newborn child
if the Covered Plan Participant provides notice
If the adopted newborn child is not enrolled
t .............. - SIT
Enrollment and Effective Date of Coverage 10-2
1214MV1911116i 0 a I , 0 - - 0 . I •
ViA-NwlwiL = - — =.tf - a
Annual Open Enrollment Period, or in the case
the- Special
E-tirollilent 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
Adopted/Foster Children - To enroll an
adopted or Foster Child, the Covered Plan
Participant must submit an Enrollment Form
during the 30-day period immediately following
the date of placement. The Effective Date for an
adopted or Foster child (other than an adopted
irew'tt,r-n-L4&f)-" ta4ia fa-A--._tTv■&l (■w
Foster child is placed in the residence of the
Covered Plan Participant in compliance with
applicable law. The Covered Plan Participant
may be required to provide any information
and/or doeyments1earrief nacessari in srfarU
properly administer this section.
UZI =—t 1kVi
a
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
Benefit Booklet during an Annual Open
Enrollment Period, or in the case of a Special
Period. For all children covered as adopted
children, if the final decree of adoption is not
issued, coverage shal I not be continued for the
proposed adopted Child. Proof of final adoption
must be submitted to BCBSF through Monroe
County BOCC Benefits Office. It is the
ras�xnslkility tf kNe Giverel Pla;% PaXiciXa;%t tt.
notify BCBSF through Monroe County BOCC
Benefits Office if the adoption does not take
place. Upon receipt of this notification, we will
terminate the coverage of the child as of the
of the written notice.
If the Covered Plan Participant's status as a
144V-14z�-1, �Ta
any Foster Child. It is the responsibility of the
Covered Plan Participant to notify BCBSF
through Monroe County SOCC Benefits Office
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
terminated.
I jj M j jjjVM= GMK9r—=-=FT3' -
Wr—�J�.&Irt r.0., Qat—TSQXAAFUM -
due to a legally valid existing marriage under
Federal Law. To apply for coverage, the
Covered Plan Participant must complete the
Benefits Office and forward it to BCBSF. The
&-afitq�-
for enrollment wn 30 days of the marriage.
The Effective Date of coverage for an Eligible
Dependent who is enrolled as a result of
marriage is the date of the marriage.
Court Order - The Covered Plan Participant
may apply for coverage for an Eligible
Dependent outside of the Initial Enrollment
Period and Annual Open Enrollment Period if a
court has ordered coverage to be provided for a
minor child under their group coverage. To
o covera■ e the Covered Plan Partic,
ze
within 30 days of the court order. The Effective
I K Tr
Enrollment and Effective Date of Coverage 1013
is enrolled as a result of a court order is the date
required by the court.
ETITIVTIUSTZ���.r`
EmployeesEligible EligibleDependent
who did not apply for coverage during the Initi
Enrollment Period or a Special Enrollment
The effective date of coverage for an Eligible
the • -establishedMonroe County
BeTefits Office.
Enrollment Period,
Annual Open EnrollmentPeriod,
Eligible. • or the EligibleDependent
enrolled
outlined in the Special Enrollment Period
subsectio,f, of ttis section.
An Eligible Employee and/or • .
enrollmentEligible Dependent(s) may apply for coverage
outside of the Initial Enrollment Period and
. apply for a
Eligible Employee and/or the Employee's
Eligible Dep•complete the
applicable Enrollment Form and forward it to
time periods noted
enrollment
An Eligible Employee and/or the Employee's
one of the following
occurs and the applicable Enrollment
submitted to Monroe County BOCC Benefits
Office within the indicated time • d
I . If you lose your coverage under another
group health benefit ..;
coverage (as an employee
or dependent), or coverage under other
health insurance (except in the case of loss
of ._
Insurance Program Medicaid,
COBRA.,
coverage that you we- covered
providedthe time of initial enrollment
a) when offered coverage under this plan
at the time of initial eligibility,. F
in writing, that coverage under a group
health plan or
enrollment;coverage was the reason for declining
and
b) you lost your other coverage under a
group health benefit plan or health
insurance ■ -■' p' in the case
of • of . _■e under a CHIP or
Medicaid, see #3 • l as of
hourstermination of employment, reduction in
the number of •work,
or `.
benefits under other health coverage,
the employer ceased offering
terminated;health coverage, death of your spouse,
divorce, legal separation or employer
contributions toward such coverage was
and
c) you submit the applicable Enrollment
Form to the Group within 30 days of the
date your• ge was terminated
Note: Loss of coverage for failure to pay
your required contribution/premium on
timely basis . ■ a
fraudulent claim or an intentional
misrepresentation of - fact in
Enrollment and Effective Date of Coverage 10
Fflr4fi Illar U* I
adoption or placement in anticipation of
adoption and you submit the applicable
Enrollment Form to Monroe County BOCC
the event.
or
you or your Eligible Dependent(s) lose
coverage under a CHIP or Medicaid due t
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 BOCC Benefits Office wit
60 days of the date such coverage was
terminated or the date you become
for the optional state premium assh t nce
program. I
Tor j'ojL 111-15 Ij
Eligible Dependents added as a result of a
special enrollment event is the date of the
ATed2l LaTroll-Tra-rit ave-mt. ees; or
T a A. IF V.
their coverage selection during the Special
Enrollment Period must wait until the next
Annual Open Enrollment Period (See the
Dependents of a Covered Plan Participant)-
Ither Provisions Regarding
Coverage
Rehired Employees
Individuals who are rehired as employees of
Monroe County BOCC or any of the
Constitutional Officers or their Employees are
of this section, The provisions of the Group
'e6Wt=AUL-C?97L' I T77
are applicable to rehired employees and their
Eligible Dependents.
Enrollment and Effecilve Date of Coverage 1-5
0 a - 0 - - 0
I:Frd U;ff -I M-1 4 - -#
A Covered Plan Participant's coverage under
at 12:01
1. on the date the Group Aealth Plar
terminates;
2. on the date the ASO Agreement between
BCBSF and Monroe County BOCC
terminates;
3. an the last day of the first month that the
Covered Plan Participant fails to continue to
meet any of the applicable eligibility
requirements;
4. on the date specified by Monroe County
BOCC that the Covered Plan Participant's
coverage is terminated for cause (see the
Termination of an Individual Coverage for
Cause subsection); or
5. on the date specified by Monroe County
BOCC that the Covered Plan Participant's
coverage terminates.
Dependenift Coverage
A Covered DependenVs coverage Mi I
.0 ft- IN temi-Fate at 112-101 a-Tnr- a.-F
1. the Group Health Plan terminates;
2. the Covered Plan Participaint' s coveragz
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 CalendarTear that the
Covered Dependent child no longer meets
any of the applicable eligibility requirements;
5. date specified by Monroe County BOCC th
the Dependents coverage is terminated fo
cause (see the Termination of Individual
Coverage for Cause subsection). I
wish to delete a Covered Dependent from
coverage, an Enrollment Form must be
forwarded to BCBSF through Monroe County
BOCC Benefits Office.
L
wish to terminate a spouse's cover -age, (e.g., i
the c _:.ase of divorce), you must submit an A 7
to the requested termination date or within 10
applicable.
Anc-
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
E. the knowing misrepresentation, omission or
the giving of false information an EnrollmeM
Forms or other forms completed, by or on
your behalf.
77TTTTA��
It is Monroe County BOCC's responsibility to
Termination of Coverage 11.1
� =�MNMIM• M
(*201 luIllAt-1-711411
I e issued to you.
Plan. Creditable Coverage may reduce th
length of any Pre-existing Condition
ftm—
had prior Creditable Coverage.
Coverage Wil be sent to you vAthin a 24-month
period after termination of coverage. You may
call the customer service phone number
indicated in this Booklet or on your ID Card to
request the certification.
I -
than a 63-day break in coverage).
Teffnination of Coverage 11-2
!III I 1 11 11 11 '1 � I 1 0 9 a■
m
A federal continuation of coverage law, known
as the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA), as
amenfel, may afXly-tz yityr QnryX HaaWli Plan.
If COBRA applies, you or your Covered
Dependents may be entitled to continue
cove 4 1
the applicable requirements, make a timely
elec■
maintain coverage.
You must contact Monroe County BOCC
Benefits Office to determine if you or your
Covered Dependent(s) are entitled to COBRA
continuation of coverage. Monroe County
obligations under COBRA, including the
lu 7
ding'
t
he
obligation to notify all Covered Persons of thei
I
ei
rights under COBRA. If you fail to meet your
obligations under COBRA and this Benefit IZ it
for any claims incurred by you or your Covere
I
Dependent(s) after termination of coverage.
A summary of your COBRA rights and the
continuation coverage is provided below.
The following is a summary of what you may
elect, if COBRA applies to Monroe County
- - - -■ — --- - -
2 period not to exceed 18 monI in the
nase of
Itel-7141IR-161011
reduced hours of employment of the
Covered Plan Participant.
*Note: You and/or your Covered
Dependent(s) are eligible for an I I month
extension of the 18 month COBRA
months) if you or your Covered
m0nts0U0roUr0ve
re d
D((SS
e
SS
p
AA
e
h
))
daa
e
tt1
ft
tthyh
(
ee
1)
tt t
ee
y
e t
o
ttC ay
*dsabled
oyomo(na,
as n
s
o of COBRA continuation coverage. The
Covered Person must supply notice of the
disability determination to Monroe County
rm
BOCC Benefits Office within 18 months of
I fr becoming eligible for continuation coverag
and no later than 60 days after the SSA's
determination date.
2. Your Covered Dependent(s) may elect to
continue their coverage for a period not to
exceed 36 months in the case of
a) the Covered Plan Participant's
entitlement to Medicare;
b) divorce or legal separation of the
Covered Plan Participant;
c) death of the Covered Plan Participant;
d) the employer files bankruptcy (subject to
bankruptcy court approval); or
e) a dependent child may elect the 36
month extension if the dependent child
ceases to be an Eligible Dependent
under the terms of Monroe County
BOCC's coverage.
Children bom to or placed for adoption w ith th el
coverage periods noted above are also eligibi
�4 for the remainder of the continuation period..
Additional requirements applicable to
cWtiTtla ' uTdar COSIPA-are-cIII
I . Monroe County BOCC must notify you of
your continuation of coverage rights under
COBRA within 14 days of the event which
creates the continuation option. If coverage
would be lost due to Medicare entitlement,
Continuing Coverage Under COBRA 12-1
divorce, legal separation or the failure of a
requirements, you or your Covered
Dependent must notify Monroe County
BOCC Benefits Office, in writing, Within 60
lays of any of these events. Monroe
r�-IFX VFhL.9L41.Cf_%F_LA. e.-
k�Tj��
2. You must elect to continue the coverage
within 60 days of the later of
a) the date that the coverage terminates; or
b) the date the notification of continuation of
coverage rights is sent by Monroe
County BO,C.
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.
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
Administration that you are no longer
disabled. You must inform Monroe County
Administration's determination within 30
days of such determination.
requirements, and all other eligibility
the Group Health Plan,
6 : -. 2 - - 6 - , A a - 0
L4111 a ilzln I I I a I E*1sAT1z4e-T**4M
An election by a Covered Plan Participant or
Covered Dependent spouse shall be deemed to
be an election for any other qualified beneficiary
related to that Covered Plan Participant or
Covered Dependent spouse, unless otherwise
specified in the election form.
Note: This section shall not be Interpreted to
grant any continuation rights In excess of
those required by COBRA and/or Section
4980B of the Internal Revenue Code.
Additionally, this Benefit Booklet shall be
deemed to have been modified, and shall be
Interpreted, so as to comply with COBRA
and changes to COBRA that are mandatory
with respect to Monroe County BOCC.
Continuing Coverage Under COBRA 12-2
PrivilegeSection 13: Conversion
•
. _..
to as a "converted policy" or "conversion policy")
it
1. you • •usly covered for
three months under the Group Health Plan
and/or under another group policy that
provided similar benefits immediately prior
the • • Health
2. your _ .. r • for
reason, including discontinuance of th
• r Health Plan in its entirety and
interested
for a converted policy, and the applicable
premium payment, within the 63-day period
beginning on the ..
Groupte the coverage under
the :.
terminated,coverage has been due to the
non-payment of employee
paymentthe completed converted policy application
and the applicable premium
the 63-day period beginning on the date
notice was given that the Group Health Pla
terminated. I
In the event BCBSF does not
convertedpolicy
paymentpremium ■. period,
your converted policy application will be denie
• T-71r=l,
1. you are eligible for or covered under the
Medicare ■ ■
2. you failed to pay, on a timely basis, the
contribution required for coverage under the
• ■ Health Plan;
under3. the Group Aealth Plan was replaced withl
31 days after termination by any group
policy, contract, plan, or program, includin']
a self -insured plan or program, that provid
benefits similar to the benefits provided
Booklet: or
categories4. a) you fall under one of the following
, meet the requirementsof
rbelow.
surgical, medical or ajmedical
policy or contract or underplan or program that provides
-
• • • or •';
• • • - •
whether on .' uninsured
or partially insured basis,
- ! those provided
under:•• or
iii. benefits similar to the benefits
provided under this Booklet are
provided for or are available to you
pursuant to or in accordance with
the requirements of any state or
federal law (e.g., COBRA,
Medicaid); and
Conversion Privilege -i'
b) the benefits provided under the sources
referred to in paragraph 4.a.i or the
benefits provided or available under the
source referred to in paragraph 4.a.ii.
and 4.a.iii. above, together with the
benefits provided by our converted
policy would result in over -insurance in
accordance with our over -insurance
standards, as determined by us.
Neither Monroe County : •
has any obligation to notify you of this
con
terminates or at any other time. It Is your
sole responsibility to exercise this
converted policy
evidencetermination of your coverage under this
Benefit Booklet. The converted policy may
be issued without
and shall be effective the day following the
rI Our • -. policies
other states'similar laws. Coverage continuation of coverage under COBRA or any
benefits provided under a converted policy
not be identical to the coverage and benefits
provided under this Booklet. When applying for
our converted policy, you have two options1) a
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
health benefit plan pursuant •:
Florida627.6699(12) Statutes. In any event,
will not be required to issue a converted policy
unless required s . ♦ so by Florida law. We
othermay have options available to you. Call
for more information.
Conversion Privilege 12
11 111111111 00 - 0 -
AN■
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
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
e-rtitled to aT eiteiTsiot of be-riefts.
L
a result of a specc Accident or illness
incurred wh lie you were covered under this
Booklet, as determined by us, a limited
te Af-ovidat wiler
this Benefit Booklet for the disabled
individual only. This extension of benefits is
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
XWtz-Oe—
month period beginning on the terminafion
date of the Group Health Plan.
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
perform those normal day-to-day acbvities
require regular care and attendance by a
Physician.
F_ In the event you are receiving covered
dental treatment as of the termination date
of the Group Health Plan a limited extension
of such covered dental treatment will be
provided under this Benefit Booklet if -
a) a course of dental treatment or dental
procedures were recommended in
writing and commenced in accordance
with the terms specified herein while you
were covered under the Group Health
Plan;
b) the dental procedures were procedures
for other than routine examinations,
prophylaxis, x-rays, sealants, or
orthodontic services; and
c) the dental procedures were performed
within 90 days after the Group Health
P" terniTated.
MPIT-ST71111
Services necessary to complete the
dental treatment only. This extension of
benefits will automatically terminate at
the end of the 90-day period beginning
on the termination date of the Group
Health Plan or on the date you become
covered under a succeeding insurance.
health mainter;ance irrganizatismsr self -
insured plan providing coverage or
Services for similar dental procedures.
You are not required to be totally
disabled in order to be eligible for this
extension of benefits.
the 'What Is Covered?" section for a
description of the dental care Services
covered under this Booklet. I
Extension of Senefift 14-T
3. In the event you are pregnant as of the
terminaflon date of the Group Health Plan, a
limited extension of the maternity expense
benefits included in this Booklet will be
available, provided the pregnancy
commenced while the pregnant individual
was covered under the Group Health Plan,
as determined by us or Monroe County
BOCC. This extension of benefits is for
Covered Services necessary to treat the
pregnancy only. This extension of benefits
will automatically terminate on the date of
the birth of the child. You are not required to
be Totally Disabled in order to be eligible for
this extension of benefits.
Extension of Benefits 14-2
continue to be eligible and covered under this
Benefit Booklet, coverage under this Benefit
Booklet will be primary and the Medicare
bexeYj����v o �the ex�tent
m.jxA--�-AV-A-rjrLslwmes-coveraoe
under this Benefit Booklet will be secondary to
any Medicare benefits. To the extent the
benefits under this Benefit Booklet are primary,
�Ir
BCSSF first.
Under Medicare, Monroe County BOCC MAY
NOT offer, subsidize, procure or provide a
Medicare supplement policy to you, Also,
Monroe County BOCC MAY NOT induce you to
coverage and elect Medicare as primary payer.
If you become 65 or become eligible for
Medicare due to End Stage Renal Disease
County BOCC Benefits Office.
VMVMTIVZUKN'105111���
Disease
if you are entitled to Medicare coverage
btacause of ESeQ-.���' -Bsns&
30 months beginning with the earlier of,
1. the month in which you became entitled to
Medicare Part "A" ESRID benefits; or
2. the first month in which you would hav
been entitled to Medicare Part "A" ES
benefits if a timely application had bee
made. ai
If Medicare was primary prior to the time you
became eligible due to ESRD, then Medicare
i i.e.. gersons entitled due4f
0 4 1
disability whose employer has less than 100
employees, retirees and/or their spouses over
the age of is if coverage under this
Benefit Booklet was primary prior to ESRD
entitlement, then coverage hereunder will
remain primary for the ESRD coordination
period. If you become eligible for Medicare due
to ESRD, coverage will be provided, as
for
30 months.
*=- 1-1-T-F-'TqT=rX-Mr-
If you are entitled to Medicare coverage
because of a disability other than ESRD,
Medicare benefits will be secondary to the
C-45-62I
provided that:
LMBE3L4=*@1'K*1=- =-- WT177-M W, W
mmv,Ima �'t- . - ]�XVAftllveo[11.11
more of its regular business days during the
previous Calendar Year. If the Group Health
Plan is a multi -employer plan, as defined by
Medicare Medicare benefits will be secondary if
at least one employer participating in the plan
on 50% or more of its regular business days
during the previous Calendar Year.
1J1t7TnMT=
1. This section shall be subject to, modified (if
necessM) to conform to or comply with,
and interpreted with reference to the
requirements of federal statutory and
regulatory Medicare Secondary Payer
provisions as those provisions relate to
Medicare beneficiaries who are covered
under this Benefit Booklet.
The Effed of Medicare Coveragel Medicare Secondary Payer Provisions 15-1
2. BCBSF will not be liable to Monroe County
BOCC or to any individual covered under
this Benefit Booklet on account of any
nonpayment of primary benefits resulting
from any failure of performance of Monroe
County BOCC's obligations as described in
ttis section.
The Effect of Medicare Coverage/ Medicare Secondary Payer Provisions 1&2
X T.-TV ff TIM - =I.
Coordination of Benefits ("COB") is a limitation
rl t$1JkT 4T_-nN -
ftis Be-reft Booklet.
will be paid when you are covered under more
than one health plan, program, or policy
providing benefits for Health Care Services.
COB is designed to avoid the costly duplication
of payment for Covered Services. It is your
responsibility to provide BCBSF and Monroe
County BOCC Benefits Office information
concerning any duplication of coverage under
any other health plan, program, or policy you or
your Covered Dependents may have. This
means you must notify BCBSF and Monroe
County BOCC Benefits Office in wrng if you
have other applicable coverage or if there is no
other coverage. You may be requested to
provide this information at inal enrollment, by
connection with a specific Health Care Service
you receive. If the information is not received,
claims may be denied and you will be
to cleTied claims.
Aeann pians, programs or po I IT ma'y lie
subject to COB include, but are not limited to,
the following which will be referred to as
"plan(s)" for purposes of this section:
n,�, ���Nurimpp
2. any group plan issued by any Blue Cross
and/or Blue Shield organization(s);
3. any other plan, program or insurance policy,
including an automobile PIP insurance
policy and/or medical payment coverage
with which the law permits coordination of
benefits;
4. Medicare, as described in "The Effect of
�L -7 .LV_7.1rJF1TM_717� -,
Payer Provisions" sectionr; and
5. to the extent permitted by law, any other
program.
The amount of payment, if any, when benefits
are coordinated under this section, is based on
whether or not the benefits under this Benefit
Booklet are primary. When primary, payment
will be made for Covered Services without
regard to coverage under other plans. When the
benefits under this Benefit Booklet are not
primary, payment for Covered Services may be
reduced so that total benefits under all your
plans will not exceed 100 percent of the total
reasonable expenses actually incurred for
Covered Services. For purposes of this section,
in the event you receive Covered Services from
an In -Network Provider or an Out -of -Network
Provider who participates in the Traditional
Program, Ototal reasonable expenses" shall
Provider pursuant to the applicable agreement
BCBSF or another Blue Cross and/or Blue
Shield organization has with such Provider. In
the event that the primary payees payment
exceeds the Allowed Amount, no payment
wil I be made for such Services.
The following rules shall be used to establish the
order In which benefits under the respective
plans will be determined:
Pupikation of Coverage Under Other Heafth Plans/Pmgrams I @F?
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 birthd
excluding year of birth, and the other
plan has covered one of the parents
longer than us, the Group Health Pla
will be secondary. 11
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 whict-
has covered you the longest shall be
primary.
The Group Health Plan will not coordinate
9::::: t 97, iTden1riW-
6. If you are covered under a COBRA
continuation plan as a result of the purcha
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 a
employee, or as the employee's
Dependent; and I
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; I
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 as a result, such plan does
not agree on the order of benefits, this
paragraph shall not apply.
b) second, the coverage purchased unde
the plan covering the person as a form
employee, or as the former employee'
Dependent provided according to the
provisions of COBRA. I
If the other plan does not have rules that
establish the same order of benefits as
under this Booklet, the benefits under the
Coordination of benefits shall not be permitted
against an indemnity -type policy, an excess
insurance policy as defined in Florida Statutes
Section 627.635, a policy with coverage limite
supplement policy.
Non -Duplication of Government
Programs and Worker's
Compensation
The benefits under this Booklet shall not
A
Duplication of Coverage Under Other Health PlanWPrograms 16-,2
Covered Dependents are entitled to or eligible
Medicare.
-dicaid. Veterans Administrationj, orWorker'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.
oupkallon of Coverage Under Other Health Plans/Programs i3
XX �-S. J
connection with or arising from a Condition
resulting, directly or indirectly, from an
and/or the Group Health Plan, to the extent of
any such payment, shall be subrogated to all
causes of action and all rights of recovery you
have against any person or entity. Such
settlement of a claim, regardless of whether
litigation has been inifiated. BCBSF may
recover, on behalf of Monroe County BOCC
aTellor Pre Groun Vealtr Plair- Vre aTrauTt of a-Fv
Monroe County BOCC's pro rata share for any
costs and attorney fees incurred by you in
pursuing and recovering damages, BCBSF may
subragate, on behalf of Monroe County BOCC
ir AT
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
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
gation as may be requested by BCBSF or
tfoTroe CouTtv BOCC. u4j"ll do whatever is
I feX;*-&5CWJ
BOCC to exercise Monroe County BOCC's
subrogation rights and shall do nothing to
prejudice such rights. Additionally, you or your
in writing of any settlement negotiations prior to
entering into any settlement agreement, shall
disclose to BCBSF any amount recovered from
any person xr-er&y that may te liatle, ant shall
not make any distributions of settlement or
judgement proceeds without Monroe County
BOCC's prior written consent. No waiver,
release of liabilltyor-. �. ants axecxtef
by you without such notice to BCBSIF shall be
binding upon Monroe County SOCC.
Subrogatbn 17W1
lilqiiii�iiq IIIIIIIIIIIII
If any payment under this Benefit Booklet is
made to you or on your behalf with respect to
act, negligence, or fault of a third person or
entity, Monroe County BOCC and/or the Grou
you recover) one dollar ($1.00) for each dollar
paid under the terms of the Group Health Plan
minus a pro rata share for any costs and
attorney fees incurred in pursuing and
recovering such proceeds. I
Monroe County BOCC's and/or the Group
Health Plan's right of reimbursement will be in
2ddition to any subrogation right or claim
2vailable 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
C,nt• — - . -alth Plan to�
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
and no waiver, release of liability, or other
exacuteg
and our written consent, acting on behalf of
Monroe County BOCC, will be binding upon
Monroe County BOCC.
Right of Reimbumement 18-1
help you understand what you or your
of this Benefit Booklet, in order to obtain
they have rendered or will render to you;
a,rd
�pplicable procedures we will use for
making Adverse Benefit Determinations,
wou 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�-Xr"a yty with a S=ma;-j Plaa XescriX�s?,
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
yxwr QrzyX Plan's sp-insir tr Xlan afministrats.-
In most cases, a plan's sponsor or plan
administrator is the employer who establishes
and maintains the plan.
ff��=
For purposes of this Benefit Booklet, there are
three types of claims: 1) Pre -Service Claims;
Urgent Care. It is important that you become
familiar with the types of claims that can be
subTlitted to us and the timeframes and other
requirements that apply.
FO-TISTIMMMid
We have defined and described the three type
of claims that may be submitted to us. Our
claim we will receive from you or your treating
Providers will likely be Post -Service Claims. I
ervices, it is %our resoonsibility to file it with us.
14• -Tri -MMA74MIll
days of the date the Health Care Service was
rendered or, if it was not reasonably possible to
file within such 90-day period, as soon as
possible. In any event, no Post -Service Claim
will be considered for payment if we do not
receive it at the address indicated on your ID
For Post -Service Claims, we must receive an
claim form. The itemized statement must
contain the following information:
1 . the date the Service was provided;
2. a description of the Service including any
applicable procedure code(s);
3. the amount actually charged by the
Provider,
4. the diagnosis including any applicable
diagnosis code(s);
S. the Provider's name and address;
6. the name of the individual who received the
Claims Processing 19-1
i I IM L#r—=, 1; 1 F ra 19-71 R 4=1
WIM
Card.
M
Program (See the "BlueCard (Out -of -State)
Program" secbon of this Booklet).
7MIM 1-TX2M14rTX*i,111LJd=
by us. Post -Service Claims will be paid,
contested, or denied within the timeframes
descdbed below.
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 I
sykmiftel Past-SeMce-glaims .-MMA 211ays
receiy�t. Likewise we will use our best efforts A
pay ( in whole or in part) for paper Post-Servic
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 th
claim is payable because we need more or
within the =1mefra=es set forth below.
.n the event we contest an electronically
zubmitted Post -Service Claim, or a portion of
iuch a claim, we will use our best efforts to
z1airn or a portion of the claim is contested. In
the event we contest a Post -Service Claim zuch a claim, we will use our best efforts to
Irovide notice, within 30 daXs of receigt. 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 addonal information is
needed in order to complete processing of the
claim. If we request additional inforrination, we
the information. If we do not receive the
_r�;K Tfh_TMM1lftfi0T_t'%r I
Infon-nation 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 16 days of receipt of the
information.
In the event we deny a Post -Service Claim
submitted electronically, we will use our best
efforts to provide notice, wn 20 days of
recei�,t that the claim or a Tortion of th claim
denied. 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 iden0fy the denied portion(s) of the
claim and the reason(s) for denial. It is your
responsibility to ensure that we receive all
informafion determined by us as necessary to
adjudicate a Post -Service Claim. If we do not
or a portion of the claim may be denied.
A Post -Service Claim denial is an Adverse
Benefit Determination and is subject to the
appeal procedures described in this section.
Service Claims I
In any event, we will use our best efforts to pay
or deny all: 1) electronic Post -Service Claims
L i
Claims Processing 19-2
and 2) Post -Service paper claims within 120
'in ' 20
days of receipt of the completed claim. Claim
processing shall be deemed to have been
decision is deposited in the mail by us or
ntlrp--itfse-eledmTkaUvAm-fsnifted. .4,-tvclali
not made by us within t7heapplicable timefram
is subject to the payment of simple interest at
the rate established by the Flornida InIsurance
Code.
We vvill 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
D*1WV;1V �_.K
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 $600.
This Benefit Booklet may condon coverage,
benefits, or payment (in whole or in part), for a
�Ou "Of
a Pre -Service Claim as that term is defined
herein. In order to determine whether we must
receive a Pre -Service Claim for a particular
Covered Service, please refer to the 'What Is
Covered?" section and other applicable sections
of this Benefit Booklet. You may also call the
customer service number on your ID card for
assistance.
Booklet require (or condition payment upon)
approval by us for the Service before it is
received.
FMM%M■ . MR-MMMIN
Involving Urcient 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
V-4
decision. If addonal 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
J, FM2AlrU'f
within 48 hours after the earlier of: 1) receipt ot
the requested information; or 2) the end of the
period you were afforded to provide the
specified additional information as described
above.
I■ - - .:: • -Mwl
that Do Not Involve Urcient Care
decision on a Pre -Service Claim not involving
urgent care within 15 days of receipt provided
additional information is not required for a
coverage decision. This 15-day determination
Xaiisl may le mdenle-Vty us t?;e time fir Y•
an additional 15 days. If such an extension is
necessary, we vAll Ys& zvr kest effz.Ks tz Xrtvi!
notice of the extension and reasons for it. We
the decision on your Pre -Service claim within
t*t!_*I if 31 d-_g-oRke ixitial receipt of tte clai
if an extension of time was taken by us.
If additional information is necessary to make a
tetermination, we will use our best efforts to:
1) provide notice of the need for additional
I information, prior to the expiration of the initial
Claims Processing 19-3
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
A Pre -Service Claim denial is an Adverse
Benefit Determination and is subject to the
appeal procedures described in this section.
Benefits for Services
A reduction or re—M—M-a-Mon or co,;eragFTr'
benefits for Serficas will M cimsiferat an
Adverse Benefit Determination when:
we have approved in writing coverage or
be provided over a period of time or a
number of Services to be rendered; an1d
the reduction or termination occurs before
the end of such previously approved time or
number of Services; and
a the reduction or termination of coverage or
benefits by us was not due to an
amendment of this Benefit Booklet or
VIT4 M11 I
will have a reasonable amount of time to have
the reduction or termination reviewed in
accordance with the Adverse Benefit
Determination standards and procedures
described below. In no event shall we be
required to provide more than a reasonable
period of time within which you may develop
your appeal before we actually terminate or
reduce coverage for the Services.
Your Provider may request an extension of
coverage or benefits for a Service beyond the
approved period of time or number of approved
Services. If the request for an extension is for a
Claim Involving Urgent Care, we will use our
of such requested extension within 24 hours
after receipt of your request, provided it is
ewi��ftl dMw&&�e4
of the previously approved number or length of
coverage for such Services. We MI use our
test eFITALs ti nititi ysw within 2-4 htva if. 1) we
need additional information; or 2) you or your
in your request for an extension. If we request
provide the requested information. We may
■
-rrl&'�-fta tiV4 tr-�tr"-13'
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
=., 01
Adverse Benefit Determination'
We will use our best efforts to provide notice of
any Adverse Benefit Determination in writing.
of charge upon request):
=-,
MMM3ZT,'Z=
4. the diagnosis codes included on the clairr
(e.g., ICD-9, DSM-M, including a
description of such codes;
E. the standardized procedure code included
on the claim (e.g., Current Procedural
Claim Processing 194
6. the specific reason or reasons for the
Adverse Benefit Determination, including
7. a description of the specific Benefit Booklet
provisions upon which the Adverse Benefit
Determination is based, as well as any
interrial. rule, guideline, protocol, or other
similar criterion that was relied upon in
making the Adverse Benefit Determination;
8. a description of any additional information
that might change the determination and
why that information is necessary;
9. a description of the Adverse Benefit
Determination review procedures and the
time limits applicable to such procedures;
10. if the Adverse Benefit Determination is
based on the Medical Necessity or
Experimental or Investigational limitations
and exclusions, a statement telling you how
to obtain the specific explanation of the
scientific or clinical judgment for the
determination; and
11. You have the right to an independent
external review through an external review
organization for certain appeals, as providef
in the Patient Protection and Affordable
may notify you orally within the proper
a or electronic notification meeting the
requirements of this subsection no later than
three days after the oral notification.
ATTANW, rL=v-F-1XTvW - WTT-OV=1
Determination
Except as described below, only you. or a
Determination. An appeal of an Adverse Benefit
TaterminaY.inwill t* raArival Ysing the review
process described below. Your appeal must be
submitted to us in writing for an internal appeal
within 365 days of the original Adverse Benefit
.1
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:
You may request to review pertinent
documents, such as any internal rule,
guideline, protocol, or similar criterion relied
upon to make the determination, and submit
0 ssi ip-, or comments in writing;
If the Adverse Benefit Determination is
based on the lack of Medical Necessity of a
particular Service or the Experimental or
Investigational exclusion, you may request,
free of charge, an explanation of the
scientific or clinical judgment relied upon, if
any, for the determination, that applies the
terms of this Benefit Booklet to your medical
circumstances;
During the review process, the Services in
question will be reviewed without regard ft
the decision reached in the initial
17- M ME T1171
•We may consult with appropriate
Physicians, as necessary:
Any independent medical consultant who
reviews your Adverse Benefit Determination
on our behalf will be identified upon request;
If your claim is a Claim Involving Urgent
Care, you may request an expedited appeal
orally or in writing in which case all
necessary information on review may be
transmitted between you and us by
telephone, facsimile or other available
expeditious method; and
Claims Processing 1416
FLT141kipli W—IsItIA4 .1;1 I'M
M111T!52r4X;TXWA19 F—;TM-1UT:- " R
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.floddablue.com or by calling the I
ITMIrl 1 107�14 T . - X-1
Benefit Determinations
We will use our best efforts to review your
communicate the decision in accordance with
T Fr1T-TM1=
7-T4- =-, STOM = W-Tj
recei t of your appeal, or
Claims Involving Urgent Care (and requestl�
to extend concurrent care Services made
within 24 hours prior to the termination of
Services)— within 72 hours of receipt of yo
request. If additional information is
necessary we will notify you within 24 hour
and we must receive the requested
additional information within 48 hours of ol
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.
has had a claim denied as not Medically
claim denial. The appeal may be directed to an
'-m7;-1Yaa►
responsible for Medical Necessity reviews. The
appeal may be by telephone and the Physician
MaK If �-'
to exceed 15 business days. Requests for an
Ir �7T �T-
below:
- . 6 a I- ma
Attention: Member Appeals
P,O. Box 44197
Jacksonville, Florida 32231-4197
How to Request External Review of
Our Appeal Decision
a decision based on Medical Necessity,
appropriateness, health care setting, level of
or treatment you requested or a determination
that the treatment is Experimental or
investigational, you are entitled to request an
independent, external review of our decision.
third party with clinical and legal expertise
("External Reviewer") who has no association
with us. If you have any questions or concerns
during the external review process, please
card or visit www.floddablue.com You may
submit additional written comments to External
Reviewer. A letter with the mailing address will
Please note that if you provide any additional
W
will be shared with us in order to give us the
opportunity to reconsider the denial. Submit
your request in writing on the External Review
your denial to the below address:
Blue Cross and Blue Shield of Florida
Attention: Member External Reviews DCC9-6
Post Office Box 44197
Jacksonville, FL 32231-4197
Claims Processing 191a
If you have a medical Condon where the
timeframe for completion of a standard external
review would seriously jeopardize your life,
A-nL- A Vyin re -Z
may file a request for an expedited external
review. Generally, an urgent situation is one in
in the opon of your Physician, you may
experience pain that cannot be adequately
controlled while you wait for a decision on the
external review of your claim. Moreover
or Health Care Service for which you received
Emergency Services, but have not been
discharged from a facility. Please be sure your
treating Physician completes the appropriate
form to inate this request type. If you have any
n _rp-m-g-%,please contact us at the phone number
listed an your ID card or visit
www.floddablue.com. You may submit
additional written comments to the External
Reviewer. A letter with the mailing address will
be sext to you w�eA yoeview.
Please note that if you provide any additional
will be shared with us in order to give us the
opportunity to reconsider the denial. If you
T qomw"
the address above or by fax to 904-565-6637.
decision, we will provide coverage or payment
for your health care item or Service.
You or someone you name to act for you may
file a request for external review. To appoint
-
of* 1 11-1 0 Ms -
kell I - - - - I i, 5 VIM' I J -U--- r M 7 -4 7 r- Pi I
and free of charge, reasonable access to, and
yttv aXAaaal
including a copy of the actual benefit provision,
guideline protocol or other similar criterion on
which the appeal decision was based.
i 'V—ViJATGF—Vxq�& L -
corresponding meanings, applicable to this
notice, if available.
Provisions
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
tur 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.
2. Physical Examination:
In order to make coverage and benefit
decisions, we may, at our expense, require
you to be examined by a health care
Provider of our choice as often as is
reasonably necessary while a claim is
pending. Failure by you to fully cooperate
of the pending claim and we shall have no
liability for such claim.
UNU2ML=
1*4k"VV..• Vim . 1. - - 1�1111
Booklet may be brought against us within
completed claim as required herein.
after expiration of the applicable statute of
limitations.
4. Fraud, Misrepresentation or Omission ir
Applying for Benefits:
We rely on the information provided an the
itemized statement and the claim form when
processing a claim. All such information,
Claims Processing 19-7
therefore, must be accurate, truthful and
complete. Any fraudulent statement,
omission or concealment of facts,
misrepresentation, or incorrect informabon
may result, in addition to any other legal
P. lxA"!RLoLffie_ctaim
or cancellation or rescission of your
dXU "__
�W=01 01=1 &=1 AWNTMI
All claims decisions, including denial and
claims review decisions, will be
written correspondence. This form may
indicate:
a) The specific reason or reasons for the
Adverse Benefit Determination;
b) Reference to the specific Benefit
Booklet provisions upon which the
Adverse Benefit Determination is based
as well as any internal rule, guideline,
protocol, or other similar criterion that
was relied upon in making the Adverse
Benefit Determination;
c) A description of any additional
information that would change the initial
determination and why that information
is necessary;
d) A description of the applicable Adverse
Benefit Determination review
procedures and the time limits
applicable to such procedures-, and
e) If the Adverse Benefit Determination
based on the Medical Necessity or
Experimental or Investigational
limitations and exclusions, a stateme
telling you how you can obtain the
specific explanation of the scientifl
clinical judgment for the determinatio
I - ' ^ - - L -
civil insurrection, epidemic, or other
liability or obligation for any delay in
payment of claims for Covered Services
except that we will make a good faith e;o
to make payment for such Services, taking
into account the impact of the event. For
purposes of this paragraph, an event is no
within our control if we cannot effectively
exercise influence or dominion over its
occurrence or non-occurrence.
Claims P=esslng 19-0
Section R Relationship
WealftCare Providers
Booklet.Neither BCBSF nor Monroe County BOCC nor
any of their officers, directors or employees
provides Health Care Services to you. Rather,
TX
this -pting the Group health
care coverage and benefits, you agree that
■ such coverage and benefit■ •e • • i-WWeV, arfarrl aft-o�hFGara-
Services
• that heafth
herebyrendering those Services are not employees or
agents of BCBSF or Monroe County BOCC. In
this regard, we and Monroe County BOCC
disclaim any agency
relationship, actual or Implied,
health care Provider. BCBSF and Monroe
County BOCC. ■• not,by of r
coverage, benefit, and payment decisions,
exercise any control or direction
medical■■ or decisions
health care Provider. Any decisions made under
the • a Health Plan concerning
appropriateness or
Service is Medically Necessary, shall be
deemed to be made solely for purposes of
■_K 0 2=1 UA:• _■ 4I
• ■ : a _ t • ■' _ a
omissions of any _Provider.
1 1XV *Ona 311 RPM
employees, or us. Additionally, neither BCBSF
■ I� ■' • :� ■-i -
in tort or contract or otherwise, for any acts or
omissions of any other person or organization
arrangements for the provision of Covered
Services. BCBSF is not your agent, servant, or
representative nor is BCBSF an agent,
or representafive of Monroe County BOCC. and
BCBSF will not be • or
agents,• or person
organization with which Monroe County BOCC
By acceptance of coverage and benefits
hereunder, you agree to the foregoing.
Medical
•
training,Any and all decisions that require or pertain to
independent professional medical judgment or
or ■ medical
supplies, must be made solely by your family
and your treating Physician in accordance with
the patient1physician relationship. It is possible
that a particular procedure is nee• a
appropriate, or desirable, even though such
procedure may not be covered.
Relationship Between the Parties 20-,1:
FTIMTTTWVJT��
BCBSF and Monroe County BOCC have the
right to receive, from you and any health care
Provider rendering Services to you, information
ihat is reasonably necessary, as determined by
BCBSF and Monroe County BOCC, in order to
administer the coverage and benefits provided,
subject to all applicable confidentiality
requirements listed below. By accepting
coverage, you authorize every health care
Provider who renders Services to you, to
disclose to BCBSF and Monroe County BOCC
or to affiliated entities, upon request, all facts,
records, and reports pertaining to your care,
A TIALC_0111�_ �
to permit BCBSF and/or Monroe County BOCC
to copy any such records and reports so
obtaft ed.
I _V771=711
Health Record Program
A care profile is available to treating Physicians
for each person covered under this Booklet. This
care profile allows a secure, electronic view of
by Physicians, Hospitals, labs, pharmacies, and
other health care Providers. Unless you have
chosen to opt out, here are a few of the benefits
of participation in the Care Profile Program:
consolidated view — or history — of your
Health Care Services, assisting them in
Wealft care.
114"W will] rZy MA I I Re
Physicians so that appropriate treatment
and Service can still be delivered.
3. Safe and secure transmission of claim
information. Only authoirized health care
Providers or authorized members of the
Provider's staff will have access to your
information.
UEEMEE=
treating health care Providers.
5. More efficient health care delivery for you.
Wtsi7-4-i-i-iditions for Mich the law
provides special protection. Health care
118.
In addition, only authorized members of the
Provider's staff will have access to the
information. Remember, this will help your
concerning your health history.
riowever, it Tor some reason jor7rm7wrm
Covered Dependents, choose not to provide
your treating Physician access to your claim
history, the use of this information may be
restricted. Should you choose not to participate
ID Card and inform a service associate of your
decision.
ITfor-fration
In order to administer coverage and benefits,
organization, obtain from any person, plan, or
1�4
General Provisions 21-1
22ZE==
Whenever the Group Health Plan has made
payments in excess of the maximum provided
for under this Booklet, BCBSF or Monroe
such payments, to the extent of such excess,
from you or any person, plan, or other
organization that received such payments.
Law� and Regulations
The terms of coverage and benefits to be
T I
. . IMFIRM
or federal laws and regulations dealing with
benefits, eligibility, enrollment, termination, or
other rights and duties.
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
connectizirwith iirna fi�e matical research ant
education, or as reasonably necessary in
connection Wth 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
judicial proceeding, or by order of a regulatory
agency, shall not be subject to this provision.
:101 1 FIR, Pai P i i WTI] i BF1 U
under this Booklet to that Provider even if
treatment has not been sought by or through
that Provider. By accepting coverage, you
hereby authorize us to release to Providers
claims information, including related medical
information, pertaining to you in order for any
such Provider to evaluate your financial
responsibility under this Booklet.
You have been provided with this Benefit
Booklet and an Identification Card as evidence
of your coverage under this Benefit Booklet.
=STNI
the Participation Status
NetworkBlue and the Traditional Provider
Program, and the participation status of
individual Providers available through BCBSF,
are subject to change at any time by BCBSF
without prior notice to you or your approval or
that of Monroe County BOCC. Additionally,
BCBSF may, at any time, terminate or modify
the terms of any Provider contract and may
enter into additional Provider contracts without
prior notice to you, or your approval or that of
Monroe County BOCC. It is your responsibility
to determine whether a health care Provider is
an In -Network Provider at the time the Health
Care Service is rendered. Under this Booklet,
your financial responsibility may vary depending
upon a Provider's participation status.
feel r T Z 6167 =-. I I T =_1 I
You must cooperate with BCBSF and Monroe
County BOCC, and must execute and submit to
us any consents, releases, assignments, and
other documents requested in order to
administer, and exercise any rights hereunder.
Failure to do so may result in the denial of
claims and will constitute grounds for termination
for cause (See the Termination of an Individual's
General Previsions 21-2
F.TWA R M_-
require the strict adherence to any of the term
I
an he el
of t t rm
or conditions described herein, will in no event
constitute a waiver of any such terms or
conditions. Further, it will not affect BCBSF's
Monroe County BOCC's right at any time to
enforce any terms or conditions under this
Benefit Booklet.
m-
e Beemea giv
by United States Mail, postage prepaid, and
addressed as listed below, Such notice will be
deposited in the mail.
If to BCBSF:
111 - a - . . - a - - 0
Card.
If to you:
To the latest address provided by you or to
your latest address on Enrollment Forms
actually delivered to us.
address change.
If to Monroe County BOCC:
Upon termination of your coverage for any
-eason, there will be no further liability or
lit
14-6 W ' I
No oral statements, representations, or
understanding by any person can change, alter,
delete, add, or otherwise modify the express
written terms of this Booklet.
Florida Agency for Health Care
T=
The performance outcome and financial data
published by the Agency for Health Care
Administration (AHCA), pursuant to Florida
Statute 408.05, or any successor statute,
located at the web site address
www.floridahealthfinder.(iov, may be accessed
Blue Shield of Florida corporate web site at
www.floridablue.com.
The terms and provisions of the Group Health
Plan shall be binding solely upon, and inure
solely to the benefit of, Monroe County BOCC.
and individuals covered under the terms of this
Benefit Booklet, and no other person shall have
any rights, interest or claims thereunder, or
under this Benefit Booklet, or be entitled to sue
for a breach thereof as a third -party beneficiary
or otherwise. Monroe County BOCC hereby
specifically expresses its intent that health care
Providers that have not entered into contracts
with BCBSF to participate in BCBSF's Provider
networks shall not be third -party beneficiaries
under the terms of the Monroe County BOCC
Group Health Plan or this Benefit Booklet.
From time to time, we may offer programs to our
customers that provide rewards for following the
terms of the program. We will tell you about any
available rewards programs in general mailings,
member newsletters and/or on our website.
Your participation in these programs is
General Provisions 211
completely voluntary and will in no way affect
Booklet. We reserve the right to offer rewards
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, I
General Provisions 2.1.4
Booklet. Other definitions may be found in the
par6cular section or subsection where they are
used.
event, other than the acute onset of a bodily
ifdrrmfty Tv ft&a&
injury. This term does not include injuries
L Ir
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 ng or chewing,
surgery, or treatment for a disease or illness.
Administrative Services Only Agreement or
r
Monroe County BOCC and BCBSF. Under th
Administrative Services Only Agreement,
BCBSF provides claims processing and
payment services, customer service, utilization]
review services and access to BCBSF's
Adverse Benefit Determination means any
denial, reduction or termination of coverage,
benefits, or payment (in whole or in part) unde
Wi Mw_ * W_VAT -
ent -it rro 947 �r te-rai-ratioir of coveynae. beielts. or navm
Adverse Benefit Determination.
1A1L.=,.CTJ =o-15 -e -46L - Ili R11mr-littall WE
upon which payment will be based for Covered
Services. The Allowed Amount maybe change'*
at any time without notice to you or your
consent.
I . In the case of an In -Network Provider
located in Florida, this amount will be
established in accordance with the
applicable agreement between that Provider
and BCBSF.
2. In the case of an In -Network Provider
located outside of Florida, this amount will
generally be established in accordance with
the negotiated price that the on -site Blue
Cross and/or Blue Shield Plan ("Host Blue")
passes on to us, except when the Host Blue
is unable to pass on its negotiated price due
to the terms of its Provider contracts. See
the BlueCard (Out -of -State) Program
section for more details.
3. In the case of Out -of -Network Providers
located in Florida who participate in the
Tradonal Program, this amount will be
established in accordance with the
applicable agreement between that Provider
and BCBSF.
4. In the case of Out -of -Network Providers
located outside of Florida who participate in
the BlueCard (Out -of -State) Traditional
Program, this amount will generally be
established in accordance with the
negotiated price that the Host Blue passes
on to us, except when the Host Blue is
unable to pass on its negotiated price due to
the terms of its Provider contracts. See the
BlueCard (Out -of -State) Program section for
more details.
In the case of an Out -of -Network Provider
that has not entered into an agreement with
BCBSF to provide access to a discount from
the billed amount of that Provider for the
specific Covered Services provided to you,
the Allowed Amount will be the lesser of that
Providees actual billed amount for the
specific Covered Services or an amount
established by BCBSF that may be based
on several factors including (but not
Definftns 22-1
necessarily limited to): (I) payment for such
Services under the Medicare and/or
Medicaid programs; (ii) payment often
accepted for such Services by that Out -of -
either in Florida or in other comparable
market(s), that BCBSF determines are
comparable to the Out -of -Network Provider
(which may include payment accepted by
such Out -of -Network Provider and/or by
far TUR IftTE
CL 191 L I t-- rdi Cj -rd fe) W
which may include, for example, other
insurance companies and/or health
maintenance organizations); (Ili) payment
amounts which are consistent, as
determined by BCBSF, with BCBSF's
provider network strategies (e.g., does not
participating in a BCBSF network to become
non -participating); and/or, (iv) the cost of
providing the specific Covered Services. In
has not entered into an agreement with
another Blue Cross and/or Blue Shield
from the billed amount for the specific
Pv.�moft-2- 6-LA LS--j3 �4'61 &J...
of -State) Program, the Allowed Amount for
the specc Covered Services provided to
you may be based upon the amount
and/or Blue Shield organization where the
organization would pay non -participating
Providers in its geographic area for such
Services.
Please specifically note that, in the case of an
Sut-of-Network. Provider that has not entered
No an agreement with BCBSF to provide
access to a discount from the billed amount of
Services. You will be responsible for any
difference between such Allowed Amount and
Ambulance means a ground or water vehicle,
to Chapter 401 of the Florida Statutes, or a
similar applicable law in another state. i
Ambulatory Surgical Center means a facility
IMYJA I _T T
provide elective surgical care to a patient,
admitted to, and discharged from such facility
within the same working day.
Wu4Uioju - LWOW-
modifications, using behavioral stimuli and
consequences to produce socially significant
ixtprovexteb&avior, ixcludirg, but
not limited to, the use of direct observation,
measurement and funcdonal analysis of the
relatiOTs beWeeT e-tviroTment and behavior.
IMM- NGFUNP-71AW-1. - -
is conducted in relation to the prevention,
17=111T71112 . - I - I ml�m=e
Prevention.
c. The Agency for Health Care Research
and Quality.
d. The Centers for Medicare and Medicaid
e, Cooperative group or center of any of
the entities described in clauses (I)
Definkions 22-2
through (iv) or the Department of
Affairs.
7-ritnWIT - I=— It.=
I 3a a 6 0 - 11ZUMLG■- Z
11111114-
2. The study or investigation is conducted
under an investigational new drug
application reviewed by the Food and Drui-r
Administration.
3. The study or investigation is a drug trial that
is exempt from having such an
investigational new drug application.
For a study or investigation conducted by a
Department the study or investigation must be
reviewed and approved through a system of
•38cmtary let■
-Y u m
s a
0
b f e
be comparable to the system of peer review 0
studies and investigations used by the Nation
ti
Ja
Institutes of Health, and (2) assures unbiased
I
review of the highest scientific standards by
qualified individuals who have no interest in th
outcome of the review.
For purposes of this definon, the term `Life -
Threatening Disease or Condition" means any
disease or condition is interrupted.
procedure in which sperm is placed into the
E-W17711 kz =—IT5-11 INITE =114 - R-1 -i
t-7L-
Diseases, Ninth Edition, Clinical Modification
(ICD-9 CM), or their equivalents in the most
recently published version of the American
Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders:
1 . Autistic disorder;
2. Asperger's syndrome;
3. Pervasive developmental disorder not
otherwise specified; and
4. Childhood Disintegrative Disorder.
Benefit Period means a consecutive peflod of
time, specified by BCBSF and the Group, in
which benefits accumulate toward the
satisfaction of Deductibles, out-of-pocket
maximums and any applicable benefit
maximums. Your Benefit Period is listed on your
Schedule of Benefits, and will not be less than
12 months unless indicated as such.
enter, apter
ir s
than a Hospital or Ambulatory Surgical Center,
which is properly licensed pursuant to Chapter
! la
383 of the Flodda Statutes, or a similar
I I
applicable law of another state, in which births
are planned to occur away from the mother's
usual residence following a normal,
uncomplicated, low -risk pregnancy.
BlueCard (Out -of -State) Program means a
national Blue Cross and Blue Shield Association
program available through Blue Cross and Blue
Shield of Florida, Inc. Subject to any applicable
BlueCard (Out -of -State) Program rules and
protocols, you may have access to the Provider
le �Ir
Blue Shield plans. See the BlueCard (Out -of -
State) Program section for more details.
�11 �Vf
a national Blue Cross and Blue Shield
Association program available through Blue
Cross and Blue Shield of Florida, Inc. Subject to
DefinKlans ZZ113
of other participating Blue Cross and/or Blue
Shield plans.
BlueCard (Out -of -State) Traditional Program
means a national Blue Cross and Blue Shield
Association program available through Blue
Cross and Blue Shield of Florida, Inc. Subject to
ATLM - -
VLTZ.�_ (611111-9
BlueCard (Out -of -State) Traditional Program
discounts of other participating Blue Cross
and/or Blue Shield plans,
BlueCard (Out -of -State) PPO Program
Provider means a Provider designated as a
'1h
by the Host Blue.
*-'rovideT means a Provider designated as a
14ueCard (Out -of -State) Traditional Program
ovider by the Host Blue.
precursor cells administered to a patient to
functions following ablative or non -ablative
therapy with curative or life -prolonging intent.
Human blood precursor cells may be obtained
from the patient in an autologous transplant, or
an allogeneic transplant from a medically
nwo6 —.ex,
be derived from bone marrow, the circulating
blood, or a combination of bone marrow and
circulating blood, If chemotherapy is an integral
part of the treatment involving bone marrow
transplantation, the term "Bone Marrow
Transplant"includes the transplantation as well
as the administration of chemotherapy and the
chemotherapy drugs. The term "Bone Marrow
TransplanValso includes any Services or
supplies relating to any treatment or therapy
and includes any and all Hospital, Physician or
blood precursor cells (e.g., Hospital room and
board and ancillary Services).
Calendar Year begins January 1 st and ends
December 31 st.
Q1FM1T_T-t!YAU1;-.-1X2; MIG"ET 11
W " NO
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,
M,914-
Certified Nurse Mldvvife means a person who
is licensed pursuant to Chapter 464 of the
Florida Statutes, or a similar applicable law of
and who is certified to practice midwifery by the
American College of Nurse Midwives.
Certified Registered Nurse Anesthetist
means a person who is a properly licensed
nurse who is a certified advanced registered
nurse practitioner within the nurse anesthetist
Statutes, or a similar applicable law of another
state.
Claim Involving ItUent-Ca— -
request or application for coverage or benefits
for medical care or treatment that has not yet
been provided to you with respect to which the
application of time periods for making non -
urgent care benefit determinations: (1) could
seriously jeopardize your life or health or your
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
Oefinftlans 22-4
i Re percentiage yol!
Coinsurance.
Concurrent Care Decision means a decision
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.
■ - 1M;JM"Tk1
shall not include any decision to deny, reduce,
or terminate coverage, benefits, or payment
as described in the "Blueprint For Health
Programs" section of this Benefit Booklet.
injury, or pregnancy.
Convenient Care Center means a properly
licensed ambulatory center that: 1) treats a
limited number of common, low -intensity
illnesses when ready access to the patient's
primary physician is not possible; 2) shares
V-V-W
in a retail business; and 4) is staffed by at leas
one masters level nurse (ARNP) who operate
It
under a set of clinical protocols that stdnctly
Although no physician is present at the
Convenient Care Center, medical ovejrsight is
is
based on a written collaborative agreement
Copayment means the dollar amount
established solely by BCBSF and Monroe
County BOCC which is required to be paid to
health care Provider by you at the time certain
J,w
Cost Share means the dollar or percentage
191HOULU A%
ut is t lim it Cost Share may includeb , ut is nonoed to
t limit t t J!V luct
n Deductible and/or P1
Admission Deductible (PAD) amounts.
Applicable Cost Share amounts are identified i
your Schedule of Benefits.
Covered Dependent means an Eligible
Dependent who meets and continues to meet all
applicable eligibility requirements and who is
enrolled, and actually covered, under the Group
Health Plan other than as a Covered Plan
Participant (See the 'Eligibility Requirements for
Dependent(s)" subsection of the "Eligibility for
Coverage" section).
Participant or a Covered Dependent.
P.1741k I
VVNL
r this Benefit Booklet other tha
Covered Services means those Health Care
Services which meet the criteria listed in the
"What Is Covered?" section.
Custodial or Custodial Care means care that
serves to assist an individual in the activities of
daily living, such as assistance in walking,
getting in and out of bed, bathing, dressing,
feeding, and using the toilet, preparation of
usually can be self-administered. Custodial
Care essentially is personal care that does not
require the continuing attention of trained
medical or paramedical personnel. In
determining whether a person is receg
Custodial Care, consideration is given to the
frequency, intensity and level of care and
medical supervision required and furnished. A
determination that care received is Custodial is
not based on the patienrs diagnosis, type of
Defirifflons 22-5
-ehabation potential.
the Allowed Amount, for Covered Services that
are your responsibility. The term, Deductible,
does not include any amounts you are
OZ-7'1 c- if-ft.,tax
or any Coinsurance/Copay amounts, if
applicable.
Detoxification means a process whereby a
alcohol or drug intoxicated, or alcohol or dru
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
4CL iwsr rn
determined by a licensed Physician or
ca
Psychologist, while keeping the physiologi
isk, 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
TA
training and educational services.
certified by the Centers for Medicare and
Medicaid Services (CMIVIS) and the Florida
services and support.
Diean means a person who is properly
licensed pursuant to Florida law or a similar
applicable law of another state to provide
management services.
furnished by a supplier or a Home Health
Agency that: 1) can withstand repeated use',
2) is primarily and customarily used to serve a
medical purpose; 3) not for comfort or
convenience; 4) generally is not useful to an
5) is appropriate for use in the home.
,ierson or entity that is properly licensed, if
ipplicable, under Florida law (or a similar
PIZ
dial iss plies in the patient's hom undera
Phy ici 's prescription, I
Effective Date means, with respect to
further described in the "Enrollment and
Effective Date of Coverage" section of this
Benefit Booklet.
Eligible Dependent means an individual who
meets and continues to meet all of the eligibility
requirements described in the Eligibility
Requirements for Dependent(s) subsection of
i
Booklet, and is eligible to enroll as a Covered
Dependent.
Eligible Employee means an active employee
ir retiree who meets and continues to meet all
if 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.
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.
mergency Medical Condition means a
.aedical or psychiatric Condition or an injury
-nanifesting itself by acute symptoms of
ihat 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
DefinitIons 22-0
condition described in clause (i), (ii), or (iii) of
plfo��N��Tr -
a medical screening examination (as
the emergency department of a Hospital,
including ancillary Services routinely
evaluate such Emergency Medical
Condon; and
2. within the capabes of the staff and
facilities available at the hospital, such
further medical examination and treatment
as are required under Section 1867 of such
Act to Stabze the patient.
anp I M =- M X �-- W-Z
Group Health Plan or this Booklet.
1�1=111 =iM, Ron - I - -
if earlier, the first day of the Waiting Period of
such enrollment.
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 BCBSF:
1. such evaluation, treatment, therapy. or
device cannot be lawfully marketed without
approval of the United States Food and
Drug Administration or the Florida
Department of Health and approval for
marketing has not, in fact, been given at the
time such is furnished to you; or
2. such evaluation, treatment, therapy. or
device is provided pursuant to a written
protocol which describes as among its
objectives the following: determinations of
safety, efficacy, or efficacy in comparison to
the standard evaluation, treatment, therapy,
or device; or
3. such evaluation, treatment, therapy, or
device is delivered or should be delivered
subject to the approval and supervision of
an institutional review board or other entity
as required and defined by federal
regulations; or
4. credible scienfific evidence shows that su&
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 under study to determine:
maximum tolerated dosage(s), toxicity,
safety, efficacy, or efficacy as compared
with the standard means for treatment or
diagnosis of the Condition in question; or
5, credible scientific evidence shows that the
consensus of opinion among experts is thal
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
2. credible scientific evidence shows that suc
evaluation, treatment, therapy, or device h
not been proven safe and effective for
treatment of the Condon in question, as
evidenced in the most recently published
Medical Literature in the United States,
Canada, or Great Britain, using generally
accepted scienc, medical, or public hea
methodologies or statistical practices; or I
7. there is no consensus among practicing
Physicians that the treatment, therapy, or
device is safe and effective for the Condition
rlrlul=ll�
DeflnftWns 22-7
8. such evaluation, treatment, therapy, or
device is not the standard treatment,
therapy, or device utilized by practicing
Physicians in treating other patients with the
same or s ri
"Credible scientific evidence'shall mean (as
determined -•
1 . records maintained by Physicians or
Hospitals rendering care or treatment to you
or other patients with the same
reports,2.
authoritative medical and scientific literature
published in the United States,.r
Great Britain;
3. published reports,
Departmentof the United States
Service,and Human Services or the United States
Public Health any of
OfficeNational Institutes of Health, or the United
States
protocols4. the written protocol or protocols relied upon
by the treating Physician or institution or the
- or institution
studying substanbally the same evaluation,
treatment, therapy, or device;
5. the written informed consent used by the
treating Physician or institution or by another
Physician or institution studying substantially
the same evaluation, treatment, therapy, or
device;
reports)6. the records (including any
institutional review board .
f any institution
which has reviewed the evaluation,
treatment, therapy, or device for the
Condition in question.
Note: Health Care Services which are
tatsrmina3!- - ,r
Investigational are excluded (see the "What
Is Not Covered?" section). In determining
whether a Health Care Service is
Ry
: .. ,
shouldexperts, as expressed In the published
authoritative literature, that usage of a
device ,; substantially confined
xecess2xj ix order • , .
effectiveness, or effectiveness compared
with • r a
FDA means the United States Food and Drug
Administration.
Foster Child means a person who is placed in
your residence and care under the Foster Care
Program by the Florida Department of Health &
Rehabilitative Services in compliance with
Florida Statutes or by a similar regulatory
agency of another state in compliance with that
state's applicable laws.
Gamete In fallopian Transfer (GIFT) means
the direct transfer of a mixture of sperm and
eggs into the fallopian tube by a qualified health
care provider. Fertilization takes place inside
the tube.
Generally Accepted Standards of Medical
Practice means standards that are based on
credible scientific evidence published in peer -
reviewed medical literature generally recognized
by the relevant medical community, Physician
Specialty Society recommendations, and the
views of Physicians practicing in relevant clinical
areas and any other relevant factors.
Gestational Surrogate means a woman,
regardless of age, who contracts, orally or in
writing, to become pregnant by means of
assisted reproductive technology without the use
of an egg from her body.
Gestational Surrogacy Contract or
Arrangement means an oral or written
agreement, regardless of the state or jurisdiction
where executed, between the Gestational
Surrogate and the intended parent or parents.
oerrnhIons 22-0
Group means - employer,labor
association, partnership, or corporation,
which coverage and benefits under this Bene
Booklet are made availableto you, and throug
Coveredwhich you and your
Covered Services
Group Health Plan or Group Plan means the
plan established _
nd maintained by Monroe
County BOCC for provision of health
under this Benefit
Health Care Services or Services includes
treatments, therapies, devices, procedures,
equipment, ..products,
biologicalremedies, vaccines, products,
pharmaceuticals,•
direction
Home Health Agency means a properly
400 of the Florida Statutes, or a similar
Home Health Care or
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,licensed
•.
in relief, symptom management, and
supportive services to terminally ill persons and
their families.
Hospital means a facility properly licensed
pursuant to Chapter 395 of the Florida Statutes,
or a similar applicable law of another state, that:
offers services which are more intensive than
those required for room, board, personal
services and general nursing care; offers
facilities and beds for use beyond 24 hours; and
regularly makes available at least clinical
laboratory services, diagnostic x-ray services
and treatment facilities for surgery or obstetrical
care or other definitive medical treatment of
similar extent.
The term Hospital does not include: an
Ambulatory Surgical Center; a Skilled Nursing
Facility; a stand-alone Birthing Center, a
Psychiatric Facility; a Substance Abuse Facility;
a convalescent, rest or nursing home; or a
facility which primarily provides Custodial,
educational, or Rehabilitative Therapies.
Note: If services specifically for the
treatment of a physical disability are
provided In a licensed Hospital which is
Osteopathicthe American
the Commission on the Acc
and Is primarily of r r,
Recognition of these facilities does not
expand ..: of Covered Services. I
only .. d: the setting where Covered
Services can be performed for coverage
■ r
Identification (ID) Card means the card(s)
issued to Covered Plan Participants under the
BlueOptions Group Health Plan. The card is not
transferable to another person. Possession of
such card in no way guarantees that a particular
individual is eligible for, or covered under, this
Benefit Booklet.
Defin ions 22-0
Independent Clinical Laboratory means a
4 83 of the Florida Statutes, or a similar
applicable law of another state, where
examinations are performed on materials or
specimens taken from the human body to
provide information or materials used in the
diagnosis, prevention, or treatment of a
Condition.
Independent Diagnostic Testing Facility
means a facility, independent of a Hospital or
Physician's office, which is a fixed location, a
mobile entity, or an individual non -Physician
practitioner where diagnostic tests are
performed by a licensed Physician or by
licensed, certified non -Physician personnel
under appropriate Physician supervision. An
Independent Diagnostic Testing Facility must be
appropriately registered with the Agency for
Health Care Administration and must comply
with all applicable Florida law or laws of the
State in which it operates. Further, such an
entity must meet BCBSF's criteria for eligibility
as an Independent Diagnostic TesUng Facility.
IrMfUlk= I If
Schedule of Benefits under the heading
Network'. Otherwise, In -Network means, when
uspiO i-r refereTce to a Provider. ftat-att`ire-thre
an In -Network Provider under the terms of this
Booklet.
In -Network Provider means any health care
Provider who, at the time Covered Services
were rendered to you, was under contract with
BCBSF to participate in BCBSF's NetworkBlue
and included in the panel of providers
designated by BCBSF as "I n-Network" for your
specific plan, (Please refer to your Schedule of
Benefits). For payment purposes under this
Benefit Booklet only, the term In -Network
Provider also refers, when applicable, to any
under the Blue Cross Blue Shield Associabon's
ZjlueCard (Out -of -State) Program.
Intensive Outpatient Treatment means
3 clinical hours of institutional care per day (24-
hour period) for at least 3 days a week and
returns home or is not treated as an inpatient
during the remainder of that 24-hour period. A
Hospital shall not be considered a "home" for
purposes of this definition.
In Vitro Fertilization (IVF) means a process in
which an egg and sperm are combined in a
laboratory dish to facilitate fertilization. If
fertilized, the resulting embryo is transferred to
the woman's uterus.
Licensed Practical Nurse means a person
properly licensed to practice pracflcal nursing
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.
body using the hand, foot, arm, or elbow. For
purposes of this Benefit Booklet, the term
L I 71A I A
the manipulation of superficial tissues: hot or
cold packs-, hydrotherapy; colonic irrigation;
thermal therapy; chemical or herbal
preparations; paraffin baths; infrared light;
the breast for Medically Necessary reasons as
determined by a Physician.
Definillons 22-to
IR11MMoll-la-IFT11WR M-i WARM
national professional journal.
Prescription Drugs which are rendered in a
Physician's office.,
rt T JL I - -
means that, with respect to a Health Care
Swike, 2 pro We WTW —1do-t-t clinical -T
judgment, provided, or is proposing or
recommending to provide the Health Care
Service to you for the purpose of preventing,
evaluating, diagnosing or treating an illness,
injury, disease or its symptoms, and that the
Health Care Service was/is:
accordance with Generally Accep"I
Standards of Medical Practice;
2. clinically appropriate, in terms of type,
frequency, extent, site of Service, duration,
and considered effective for your illness,
injury, or disease or symptoms;
3. not primarily for your convenience, your
family's convenience, your caregiver's
convenience or that of your Physician or
other health care Provider, and
4. not more costly than the same or similar
Service provided by a different Provider, b
way of a different method of administration
an alternative location (e.g., office vs.
inpatient), and/or an alternative Service or
sequence of Services at least as likely to
produce equivalent therapeutic or diagnos
results as to the diagnosis or treatment of
your illness, injury, disease or symptoms. I
When determining whether a Service is not
Wwpq-_p����o �requiredd
to, take into consideration various factors
including, but not limited to, the following,
a. the Allowed Amount for Service at the
location for the delivery of the Service
versus an alternate setting;
b, the amount we have to pay to the proposed
particular Provider versus the Allowed
Amount for a Service by another Provider
including Providers of the same and/or
different licensure and/or specialty; and/or,
c. an analysis of the therapeutic and/or
diagnostic outcomes of an alternate
treatment versus the recommended or
performed procedure including a
comparison to no treatment. Any such
analysis may include the short and/or long-
term health outcomes of the recommended
or performed treatment versus alternate
treatments including an analysis of such
outcomes as the ability of the proposed
procedure to treat comorbidities, time to
disease recurrence, the likelihood of
additional Services in the future, etc.
Note: The distance you have to travel to receive
a Health Care Service, time off from work,
are required to consider when evaluating
whether or not a Health Care Service is not
more costly than an alternative Service or
sequence of Services.
be based on comparative eff7ecfiveness
t
research, where available, or on evidencel
I I
showing lack of superiority of a particular
QzMPz--z0-
respect to a particular Service. In performin �o
Medical Necessity reviews, we may take into
proprietary.
It is important to remember that any review of
of determining coverage or benefits under this
Booklet and not for the purpose of
reoirxkvem1ixg or providixg Tredical care. ft ttis
information pertaining to you. Any such review,
DeflnRions 22-11
however, is strictly for the purpose of
•rif T T
Service provided or proposed meets the
definiti*n if Malical Necessity in this Bt'WW_-RS__
determined by us. In applying the definition of
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
11 , 1, - -
rL,4To=4101-i 6, lid I -
Medicare means the federal health insurance
vo-Videt UrIfarTle*M
Act and all amendments thereto.
IMMiM. ;rMUMPaMs
issued by us where you may find information
Prescrinifton Drugs that
reg�ft Xiz�tr--_ir,,=5!-Sz auft`z2V1[:! RVA—T-0-
Administered Prescription Drugs that may be
covered under this plan.
Note: The Medication Guide is subject to
change at any time. Please refer to our website
at www.floridablue.com for the most current
guide or you may call the customer service
phone number on your Identification Card for
Mental Health Professional means a person
properly licensed to provide mental health
Statutes, or a similar applicable law of another
state- This professional may be a clinical social
Mental and Nervous Disorder means any
on I an d N
"ous � "sord r■
means
any
b f■
Disease (ICD_9
e uivalents in the
n 0 Ic �a 0
International Classification of Disease (ICD-9
CM or ICD 10 CM), or their equivalents in the
Psychiatric Association's Diagnostic and
W
Statistical Manual of Mental Disorders,
regardless of the underlying cause, or effect, of
the disorder.
of another state.
by BCBSF which is available to individuals
that BCSSF's Preferred Patient Care (PPC)
preferred provider network is not available to
individuals covered under this Benefit Booklet.
!Fccupatlonal Therapist means a person
properly licensed to practice Occupational
state.
follows an illness or injury and is designed to
help a patient learn to use a newly restored or
previously impaired function.
body part or restrict or eliminate body
movement.
to Covered Services, the level of benefits
payable to an Out -of -Network Provider as
designated on the Schedule of Benefits under
the heading "Out -of -Network". Otherwise, Out -
of -Network means, when used in reference to a
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
Definftions 22.12
2. did not have a contract with a Host Blue to
participate in its local PPO Program for
purposes of the BlueCard (Out -of -State)
PPO Program but was participating, for
purposes of the BlueCard (Out -of -State)
Program, as a BlueCard (Out -of -State)
Traditional Program Provider; or
3. did have a contract to participate in
NetworkBlue but was not included in the
panel of Providers designated by us to be
In -Network for your Plan; or
4. did not have a contract with us to participatz
in NetworkBlue or our Traditional Program;
or
5. did not have a contract with a Host Blue to
participate for purposes of the BlueCard
(Out -of -State) Program as a BlueCard (Out -
of State) Traditional Program Provider.
Z
licensed pursuant to Florida law or the similar
1herapy: outpatient speech therapy; outpatient
occupational therapy; outpatient cardiac
rehabilitation therapy; and outpatient Massage
�Tea�a WkrWI-P=V--w�t� �,
a bodily function impaired or eliminated by a
Condition. Further, such an entity must meet
BCBSF's criteria for eligibility as an Outpatient
Rehabilitation Facility. The term Outpatient
Rehabilitation Facility, as used herein, shall not
include any Hospital including a general acute
care Hospital, or any separately organized unit
of a Hospital, which provides comprehensive
medical rehabilitation inpatient services, or
rehabilitation outpatient services, including, but
hospital" described in Chapter 59A, Florida
IT MI. 7m�
res for ain assessment. medication
117.7 =I- MMZ'F.FTT1M- 1-1�14TIRMF a 1 0 a a 11
programs featuring multidisciplinary Services
directed toward helping those with chronic pain
to reduce or limit their pain.
Partial Hospitalization means treatment in
which an individual receives at least 6 clinical
hours of institutional care per day (24-hour
period) for at least 5 days per week and returns
remainder of that 24-hour period. A Hospital
this definition.
Physical Therapy means the treatment of
disease or injury by physical or mechanical
Statutes or a similar applicable law of another
state. Such therapy may include traction, active
or passive exercises, or heat therapy.
Physical Therapist means a person properly
licensed to practice Physical Therapy pursuant
to Chapter 486 of the Florida Statutes, or a
similar applicable law of another state.
licensed by the state of Florida, or a similar
or a 3s
Doctoar 1. ]"of
applicable law of another state, as a r of C
Medicine (M.D.), Doctor of Osteopathy (D.O.),
Doctor of Podiatry (D.P.M.), Doctor of
D—e—nWilie-cOff e7JL71—&=J7ff -17, VARIUM
Optometry (O.D.).
.1censea 'W
*'1f1L1rL;1X11rYw
diplomates certified by a board recognized by
the American Board of Medical Specialties.
Post -Service Claim means any paper or
benefits, or payment for a Service actually
provided to you (not just proposed or
recommended) that is received by us on a
befiniflons 22-13
properly completed claim form or electronic
41 p rovoVi
isions of this sectfion.
Pre -Service Claim means any request or
-tr ken~3r-
v"eAitlh
Mat has not yet been provided to you and wit
conaition paym
part) on approval by us of coverage or benefits
for the Service before you receive it. A Pre -
Service Claim may be a Claim Involving Urgen
Care. As defined herein, a Pre -Service Claim
shall not include a request for a decision or
opinion by us regarding coverage, benefits, or
rendered to you if the terms of the Benefit
Booklet do not require (or condition pay
T lip
L A
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
ihat is properly licensed, if applicable, under
Florida law, or a similar applicable law of
the design and fabrication of medical devices
such as braces, splints, and artificial limbs
prescribed by a Physician.
Prosthetic Device means a device which
has a 6-9 0 9-1 a W
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.
Z 4 WM74- V -
to practice psychology pursuant to Chapter 490
of the Florida Statutes, or a similar applicable
law of another state.
Registered Nurse means a person properly
licensed to practice professional nursing
or a similar applicable law of another state.
Registered Nurse First Assistant (RNFA)
means a person properly licensed to perform
surgical first assisting services pursuant to
Chapter 464
applicable law of another state.
1 •leq iia n -ro.-
injury or surgical procedures including but not
limited to cardiac rehabation, pulmonary
rehabilitation, Occupational Therapy, Speech
Therapy, Physical Therapy and Massage
Therapy. I
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
or Cardiac Therapy.
an FDA -approved Prescription Drug that you
Definitions 22-14
�_.�gA(IJLTr&T rzrm 1
"_4111-11- J 77
a Physician.
,dRN*,t,t11
part thereof which meets BCBSF's criteria for
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 Tooth means teeth that are
whole or properly restored (restoration with
.W rt7j
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. I
Specialty Drug means an FDA -approved
Prescription Drug that has been designated,
P,Rft,_k, us as a Snecial .. Drup, due to snecial
handling,, storage, training, distribution
requirements and/or management of therapy.
&Ace
or self-administered and are identified with a
special symbol in the Medication Guide.
Specialty Pharmacy means a Pharmacy that
has signed a Participating Pharmacy Provider
Agreement with us to provide specific
Prescription Drug products, as determined by
us, In -Network Specialty Pharmacies are listef
IT, fte Medication Guide.
Speech Therapy means the treatment of
speech and language disorders by a Speech
language restorative therapy services.
Stabilize shall have the same meaning with
Act.
Speech Therapist means a person properly
0, .0.
applicable law of another state.
Standard Reference Compendium means:
1) the United States Pharmacopoeia Drug
Information; 2) the American Medical
Hospital Formulary Service Hospital Drug
Information.
Substance Abuse Facility means a facility
applicable law of another state, to provide
necessary care and treatment for Substance
denco. For the Wrroses of this Booklet 9
Substance Abuse Facility is not a Hospital or a
Psychiatric Facility, as defined herein.
Substance Dependency means a Condition
or her health; interferes with his or her social or
lose 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 term
Traditional Program also refers, when
organizations as designated under the Blue
Cross and Blue Shield Association's BlueCard
Traditional Program Providers means, or
refers to, those health care Providers who are
the time you received Services from them were
participating in the Traditional Program. For
Definftions 22-15
Aurposes of payment under this Benefit Booklet
inly, the term Traditional Program Provider also
refers, when applicable, to any health care
rendered to you, participated as a BlueCard
Traditional Provider under the Blue Cross and
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 ■
after 5:00 p.m. on weekdays or on Saturday or
Sunday; 2) posts instructions for individuals
public place, as • where to • such
Services when the • Care Center is
or more Board _• or Board ■
Physicians • Registered Nurses (RNs) who
are physically present during all hours ■
operation. Physicians, RNs, and other medical
I I ■ *I
a I V I - I mlarzr.9313���
Care Center is not a Hospital, Psychiatric
Facility, Substance Abuse Facility, Skilled
Nursing Facility or Outpatient Rehabation
Facility.
Waiting Period means the length of time
established by Monroe County SOCC which
must be ■ by an individual before that
iT��ias 654le i'turc-a-Vafaza W11
this Benefit Booklet. I
L
process in which an egg is ferzed in the
to the fallopian tube at the pronuclear stage
(before cell division takes place). The eggs are
retrieved and fertilized on one day and the
zygote is transferred the following day.
Definhions 22-16
Qualified Medical Child Support Ordem - The Plan will provide benefits as required by any
Qualified Medical Child Support Order (MCSO). A MCSO can be either: 1) A Qualified Medical Child
Support Order (MCSO) that satisfies the requirements of Section 609(a) of ERISA; or 2) A National
Upon receipt of a MCSO or NMSN by a Covered Employee/Retiree notification must be given to the
Monroe County Group Health Plan Administrator (Benefits Office) within 31 days of receipt. The Covere"
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.
a part of the current Benefit Booklet and any
Endorsements attached thereto. The Benefit
Booklet is amended as described below to
provide coverage for a Domestic Partner of a
Covered Employee (employee only) and, if
applicable, the dependent child(ren) of a
Domestic Partner.
or opposite sex with whom the Covered
Employee (employee only) has established a
Domestic Partnership.
6. the Covered Employee has completed and]
submitted any required forms to the Group
and the Group has determined the Domes
Partnership eligibility requirements have
bees, met.
Eligibility for Coverage
of Domestic Partners Eligibility
coverage under the Benefit Booklet:
1, the Covered Employee's (employee only)
present Domestic Partner,
Domestic Partnership means a relationship 2. the Covered Domestic Partner's dependent
between a Covered Employee (employee only) child(ren), who is under the limiting age, who
and one other person of the same or opposite meets all of the following eligibility
sex who meet at a minimum, the following requirements, and the eligibility requirements
eligibility requirements: under the Benefit Booklet:
1 . both individuals are each other`5 sole
Domestic Partner and intend to remain so
indefinitely;
2. individuals are not related by blood to a
degree Of closeness (e.g., Siblings) that
would prohibit legal marriage in the state in
which they legally reside;
3. both individuals are unmarried, at least 18
years of age, and are mentally competent to
consent to the Domestic Partnership;
4. both individuals are financially
interdependent and have resided together
continuously in the same residence for at
least six months prior to applying for
coverage under the Benefit Booklet and
intend to continue to reside together
indefinitely;
5. the Covered Employee has submitted to the
Group acceptable proof of evidence of
common residence and joint financial
responsibility; and
ASO Dom Part with Dep END
Plan 03559
a. resides regularly with the Covered
Employee and the Domestic Partner, or
the Domestic Partner is required to
provide coverage for the child(ren) by
court order, or
b. the children) qualifies as the Domestic
Partner's dependent(s) for tax purposes
under the federal guidelines; and
c. the child(ren) meets and continues to
meet the eligibility requirements as
outlined in the Eligibility Requirements
for Dependent(s) subsection of the
Benefit Booklet.
Domestic Partner Enrollment Forms/
Electing Coverage
When an Eligible Employee is making
application for coverage for his/her Domestic
ILI 1 0
Domestic Partner, and Employee/Spouse
Coverage is available under the Group's
program, Employee/Spouse Coverage is
redefined as Employee/Domestic Partner
Coverage.
an e0giDie
Partnees dependent child(ren) during the
the Benefit Booklet:
1. employee's Initial Enrollment Period;
E. Annual Open Enrollment Period: —
4. within the 30-day period immediately
following the satisfaction of the eligibility
requirements of the Domestic Partnership.
Termination of a Domestic Partneir's
WKWA-13-MMM
Child(ren)ls Coverage
In addition to the provisions stated in the
Termination of a Covered Dependent's
Covered Domestic Partner's and the Covered
Domestic Partners Covered Dependent
child(ren)'s coverage under the Benefit Booklet
will terminate at 12:01 a.m. on the date that the
Domestic Partnership terminates or the date of
death of the Covered Domestic Partner. The
liqla U...M.Rim
requirements are no longer met or within 30
days of the death of the Covered Domestic
Partner.
Covered Domestic Partners are not entitled to
Slip&
under Monroe County employment1personnel
ASO Dom Part with Dap END
Plan 03559
I "WITATRITIrT.V711i7m:
the MCBCC Group Health Plan.
inc)Mrf
spouse is referenced.
This Endorsement shall not extend, vary, alter,
renlace. or,4rtive any of the provisions, benefitl
MW
the Benefit Booklet, other than as specifically
stated in the provisions contained in this
Endorsement. In the event of any
In
5
d in
pe
th
S a c
i fic
' al
y
inconsistencies between the provisions
contained in this Endorsement and the
provisions contained in the Benefit Booklet, th
provisions contained in this Endorsement shall
control to the extent necessary to effectuate th,
intent as expressed herein.
Serviced By
PEN
ON M W-47, T Me
Schedule of Benefits — Plan 03559
Important things to keep in mind as you review this Schedule of Benefits:
• This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your
benefits can be found.
• NetworkBlue Is the panel of Providers designated as In -Network for your plan. You should always
verify a Provider's participation status prior to receiving Health Care Services. To verify a Provider's
specialty or participation status, you may contact the local BCBSF office or access the most recent
BlueOptions Provider directory on our website at www.flaridablue.com. If you receive Covered
Services outside the state of Florida from BlueCardo participating PPO Providers, payment will be
made based on In -Network benefits.
• References to Deductible are abbreviated as "DED".
• Your benefits accumulate toward the satisfaction of Deductibles, Out -of -Pocket Maximums, and any
applicable benefit maximums based on your Benefit Period unless indicated otherwise within this
Schedule of Benefits.
YourBenefit Period ................................................................................................................. 01101 — 12131
Deductible, Coinsurance and out -of -Pocket Maximums
Benefit Description MENEM=
Deductible (DED)
Per Person per Benefit Period $400
Per Family per Benefit Period $800
Per Admission Deductible (PAD) MMMM��
Emergency Room Per Visit Deductible (PVD)
Coinsurance
(The percentage of the Allowed Amount you
pay for Covered Services)
J_ier Person per Benefit Period
Per Family per Benefit Period
oluaOpWns ASO
Plan 03559 PC
a 0 L - k, - A
iM
55%
Amounts incurred for In -Network Services will only be applied to the amounts listed in the In -Network
otlymn an� arAUMS i=wel fi&Jryt-zf-Ne ".t.rk 'EoOces will zAly le 2XXIlet tt tXe 2�xzuxts listel ix
the Out -of -Network column, unless otherwise indicated within this Schedule of Benefits. This includes
tke Deductible and Out -of -Pocket Maximum amounts.
What applies to out-of-pocket maximums? 6 DIED
a PAD, when applicable
• Coinsurance
• Copayments
• PVD, when applicable
What does not apply to out-of-pocket
maximums?
Non -covered charges
Any benefit penalty reductions
Charges in excess of the Allowed Amount
Important information affecting the amount you will pay:
• Review this Schedule of Benefits carefully; it contains important information concerning your share of
the expenses for Covered Services you receive. Amounts listed in this schedule are the Cost Share
amounts you pay.
• Your Cost Share amounts will vary depending upon the Provider you choose, the type of Services
you receive, and the setting in which the Services are rendered.
• Payment for Covered Services is based on our Allowed Amount and may be less than the amount
the Provider bills for such Service. You are responsible for any charges in excess of the Allowed
Amount for Out -of -Network Providers.
0 If a Copayment is listed in the charts that follow, the Copayment applies per visit.
BlueOptions ASO
Plan 03559 PC 2
Office Services
A Family Physician is a Physician whose primary specialty is, according to CSF's records, one of the
following: Family Practice, General Practice, Internal Medicine, and Pediatrics.
Benefit Description
In -Network
Out -of- Network
Office visits and Services not otherwise outlined in
this table rendered by:
Family Physicians:
a) Office visit only
25
DIED + 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
25
DED + 55%
b) All Services other than office visit
DED + 25%
DED + 55%
Advanced Imaging Services
(CT/CAT Scans, MIAs, MRls, PET Scans and
DED + 25%
DED + 55%
nuclear cardiology)
All other diagnostic Services (e.g., X-rays)
DIED + 25%
DED + 55%
Allergy Injections rendered by:
Family Physicians
10
DED + 55%
Other health care professionals licensed to
10
DED + 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 Medical Equipment, Prosthetics, and
DED + 25%
DED + 55%
Orthotics
Convenient Care Centers
$25
DED + 5%
Chiropractic Services
DED + 25%
DED + 5°�
Note: Includes office and free-standing facilities
Preventive Health Services
Benefit Description
In -Network
Out -of -Network
Adult Wellness Services
Rendered by:
$0
55%
Family Physicians
Other health care professionals licensed to
$0
55%
perform such Services
All other locations
$0
55%
Adult Well Woman Services
Rendered by:
$0
55%
Family Physicians
Other health care professionals licensed to
$0
55%
perform such Services
All other locations
$0
55%
it Health Supervision Services
Rendered by:
Family Physicians
$0
55%
Other health care professionals licensed to
$0
55%
perform such Services
All other locations
$0
55%
Mammograms
$0
$0
Routine Colonoscopy
$0
$0
Benefit Description
Out -of -Network
independent Clinical Lab
Independent Diagnostic Testing Facility
Advanced Imaging Services (CTICAT Scans,
MRAs, MRls, PET Scans and nuclear
DED
medicine)
All other diagnostic Services (e.g., X-rays)
DED + 55%
lit
SeHo e spital Services
Outpatient
i
Benefit Description
In -Network
Out -of -Network
Prescription Drugs administered in the office by:
Family Physicians
20%
DED + 50%
Physicians other than Family Physicians and
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.
1 r. Out -of -Network
Ambulance Services DED + 25%
Emergency Room Visits See Hospital Services
Emergency Room Visits
Urgent Care Center
a) Office visit only
b) All Services other than office visit
Benefit Description In -Network Out -of -Network
Ambulatory Surgical Center
Facility (per visit) DED + 25% DED + 55%
Radiologists, Anesthesiologists, and DED + 25% DED + 25%
Pathologists
Other health care professional Services DED + 25% DED + 55%
rendered by all other Providers
Outpatient Hospital Facility See Hospital Services
Outpatient
Blue0plim AS
pan 03559 PC
5
0 M. rn un=
In -Network
Option 11* option 2*
Out -of -Network and
Benefit Description
and Out -of -State
Traditional
BlueCarcf
Providers
I Participating
Inpatient
$150 PAD + DED +
Facility Services ( per admission)
$150 PAD + DED + 25%
55%
Physician and other health care
DED + 25%
DED + 25%
professional Services
Outpatient
Facility (per visit)
DED + 25%
DED + 55%
Physician and other health care
DED + 25%
DED + 25%
professional Services
Therapy Services
DED + 25%
DED + 55%
Emergency Room Visits
$100 PVD + DED +
Facility
$100 PVD + DED + 25%
25%
Physician and other health care
DED + 25%
DED + 25%
professional Services
Important:
Certain categories of Providers may not be available In -Network in all geographic regions. This includes,
but is not limited to, anesthesiologists, radiologists, pathologists and emergency room physicians. 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 Physiciar
who is not In -Network, or a Physician who is not participating in our Traditional Program, you will be
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 In -Network DED and Out -of -Pocket Maximums.
'Piease reter to Me curre
Hospital.
Benefit Description
In -Network
Out -of -Network
Mental Health and Substance Dependency Care
and Treatment Services
Outpatient Facility Services rendered at:
Emergency Room
$75 PVD + DED + 25%
$75 PVD + DED + 25%
Hospital
DED + 25%
DED + 55%
Physician Services at Hospital and ER
DED + 25%
DED + 25%
Physician and other health care professionals
licensed to perform such Services
Family Physician office:
a) Office visit only
$20
DED + 55%
b) All Services other than office visit
DED + 25%
DED + 55%
Specialist office,
a) Office visit only
$20
DED + 55%
b) All Services other than office visit
DED + 25%
DED + 65%
All other locations
DED + 25%
DED + 66%
Inpatient
Facility Services
$150 PAD + DED 25%
$150 PAD + DED 55%
Physician and other health care professionals
DED + 25%
DED + 25%
S rvi such
licensed to perform such S:e:rvices
RKWU
Vf.T1111Y,F1_T,JU�
Benefit Maximums
Home Health Care Visits per Benefit Pedod .............................................................................................. 40
...................................................................... 30
Note: Spinal Manipulations are limited to 26 visits per Benefit Period and accumulate towards the
Outpatient Therapies and Spinal Manipulations benefit maximum. Refer to the Benefit Booklet for
reimbursement guidelines.
itPe a ........ ....................... .......................................... Unlimited
Benefit Maximum Carryover
Iwff QMn1PF.j - . j1jj6CjjjM1jW_ Ur.
inuer-27-pWrorgm-Ep-pumy-u-i i P Nbtacwwj -0 - - I - -- ...... -
to your Benefit Period maximums under the prior BCBSF or Health Options, Inc. policy will be applied
toward your Benefit Period maximums under this plan.
4
t, T Y 4
�' �' � �
� ;�
�: " m * � �'
L 4 '4 i
N ii i /
t� �k
i
f
W d Y
T �, 5 -n 4 �
��
-k t 4
i
L
� M
t
5
wf k � �, fi
� '. x:, s'
.f
} ,4, 1
M' ht+ .r
k
* 44
y :1 is 'i
�`.
y � a
+'
4 f' s" ++�
Y, i
+, +Y. 'T T� � � y
y�� k
y4 a} y
_; � },. ,
:.. ; , T 4 4
%V tetl P•d {*6 Cd 4� 6'8 CD k"$ � g C9 d'] 9 f i`7 l!
[V dnl C�tl Qm! N L4 Cd 609 Ci SY 8i9 hB C'�6 dV E°�S 6V FJ 8V6 CV �VV S� dm8 te6 FV Pi {W fV iV
Y r � � � � �
fF iY
y ,s T 1:
� Y{
I
0 0 o o 0 Q Q Q 0 m 0 0 0 0 a 0 0 0 0 0_
0 0 0 0 0 0 0 0 0 0 0 0 0 0 a m a 0 a 0 0
mmm
■
9 9 gig 2 8 R L.
RRRRRRRRERRRRRas
9 Bass 2 a a Bass
IF I
mmmm
RRRRROURRRRR2R2222 822292202
lassos sommams
I
� n T
pry m
ra
th
Ul
co
N
Pl-
v
in
0s P4
to rlt
cep
o
ra
T
PI!IR
w
P-
N
Q-
A
to
Qa
0
in
0
M.
co
V)
lw�
9`m
4%N
w
to
69
0
fad
ai
CV
0
co
CR N
tD .93 3 UJ
69 Lo
CN
co
0
m
00
0
0
Cb U3
q
co
LO
2
;
1p
co
0)
La m
co co
v
Cb
Ln
0
N
0
Cl)
0
0
Im
0 V3
;
cq
m
0
co
V.
0
0
w
Ck
LO
O�
r-
kq
Ln to
40 ct
ka
fis
Gpk
t4
w
I
v LO w ems- m
I
0 ulj
0
0)
N
v
P
0
w
P-
2
tl�
IR
t":
N0)
CD
v
v V2
lol
0
0)
i
Ro
w 0
0
Ln
N
cm
N
td
Ub
V�
61
I,.
G*
I,
VP
0
&4
ww
G*
RP
•
V) U) w r LU 2 DO OOO Z—= OLU MCL UIL) L)al
z
U) U) W U) W
0 !�
v t �e � v N N N 74 N