Item C11 BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: December 10, 2014 Division: Employee Services
Bulk Item: Yes X No — Department: Employee Benefits
Staff Contact Person/Phone#: Maria Gonzalez Ext. 4448
AGENDA ITEM WORDING: Approval of the 2014 Blue Options Benefit Booklet for Covered Plan
Participants of Monroe County BOCC Group Health Plan (a.k.a. Plan Document).
ITEM BACKGROUND: Most of the changes to the document were to maintain compliance with the
Patient Protection&Affordable Care Act(PPACA).
• Updated language for the Mental Health Parity and Addiction Equity Act with final rules;
• Removal of Section 9 and other language which covered pre-existing conditions, Under
PPACA there are no longer exclusions for pre-existing conditions.
• Modifications to definitions: Partial Hospitalization; the addition of ICD-10 in the definition of
Mental and Nervous Disorders; the addition of a definition for Intensive Outpatient Treatment;
• Substantial re-write of the Medical Necessity section that tightens up that definition;
• Language has been added to define Clinical Trials since they are now required coverage under
certain circumstances;
• Re-write of the language for requesting an external review with specific instructions, as
required;
• Other minor modifications to clarify some language but, in our opinion, the document
accurately reflects the benefits and administrative processes that our plan offers.
PREVIOUS RELEVANT BOCC ACTION: BOCC approved the 2013 Blue Options Benefit
Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan(a.k.a. Plan
Document) at the November 20, 2012 meeting,
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATIONS: Approval
TOTAL COST: INDIRECT COST: BUDGETED: Yes No
DIFFERENTIAL OF LOCAL PREFERENCE:
COST TO COUNTY: SOURCE OF FUNDS:
REVENUE PRODUCING: Yes— No AMOUNT PER MONTH Year
/'kk / JL
APPROVED BY: County Atty�,_ OMB/Purchasing V1 Risk Management
DOCUMENTATION: Included Not Required
DISPOSITION: AGENDA ITEM N
.......................
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—1/1114
Divisions 001,C01,R01,R02,002
Table of Contents
Section 1: How to Use Your Benefit Booklet..............................................................1-1
Section 2: What Is Covered?.....................................................................................2-1
Section 3: What Is Not Covered?...............................................................................3-1
Section 4: Medical Necessity.....................................................................................4-1
Section 5: Understanding Your Share of Health Care Expenses...............................5-1
Section 6: Physicians, Hospitals and Other Provider Options ...................................6-1
Section 7: BlueCarda (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
Section22: Definitions...............................................................................................22-1
Table of Contents II
Section 1: How to Use Your Benefit Booklet
This is your Benefit Booklet ("Booklet'). It be coordinated with other policies or plans;
describes your coverage, benefits, limitations and the Group Health Plan's subrogation
and exclusions for the self-funded Group Health rights and right of reimbursement.
Benefit Plan ("Group Health Plan" or"Group
Plan") established and maintained by Monroe You will need to refer to the Schedule of
County BOCC. Benefits to determine how much you have to
pay for particular Health Care Services.
The sponsor of your Group Health Plan has
contracted with Blue Cross Blue Shield of When reading your Booklet, please
Florida, Inc. (BCBSF), under an Administrative remember that.
Services Only Agreement("ASO Agreemenf'), •
to provide certain third party administrative You should read this Booklet in its entirety in
services, including claims processing, customer order to determine if a particular Health Care
service,and other services, and access to Service is covered.
certain of its Provider networks. BCBSF • the headings of sections contained in this
provides certain administrative services only and Booklet are for reference purposes only and
does not assume any financial risk or obligation shall not affect in any way the meaning or
with respect to Health Care Services rendered to interpretation of particular provisions.
Covered Persons or claims submitted for • references to"you"or"your"throughout refer
processing i under this Benefit Booklet for such to you as the Covered Plan Participant and to
Services. The payment of claims under the your Covered Dependents, unless expressly
Group Health Plan depends exclusively upon stated otherwise or unless, in the context in
the funding provided by Monroe County BOCC. which the term is used, it is clearly intended
You should read your Benefit Booklet carefully otherwise. Any references whiich refer solely
before you need Health Care Services. It to you as the Covered Plan Participant or
contains valuable information about: solely to your Covered Dependlent(s)will be
• your BlueOptions benefits; noted as such.
• what is covered; • references to"we", "'us", and "our"throughout
refer to Blue Cross and Blue Shield of
•' what is excluded or not covered; Florida, Inc. We may also refer to ourselves
• coverage and payment rules; as"BCBSF".
• Blueprint for Health Programs; • if a word or phrase starts with a capital letter,
it is either the first word in a sentence, a
• how and when to file a claim; proper name, a title, or a defined term. If the
• how much, and under what circumstances, word or phrase has a special meaning, it will
payment will be made; either be defined in the Definitions section or
• defined within the particular section where it
what you will have to pay as your share; and is used.
• other important information including when
benefits may change; how and when
coverage stops; how to continue coverage if
you are no longer eligible; how benefits will
How to Use Your Benefit Booklet
�.t
Where do you find information on........
• what particular types of Health Care • how to add or remove a Dependent?
Services are covered?
Read the"Enrollment and Effective Date of
Read the"What Is Covered?"and"What Is Coverage" section.
Not Covered?" sections.
• what happens If you are covered under
• how much will be paid under your Group this Benefit Booklet and another health
Health Plan and how much do you have to plan?
pay?
Read the "Duplication of Coverage Under
Read the"Understanding Your Share of Other Health Plans Programs"section.
Health Care Expenses"section along with the
Schedule of Benefits. • what happens when your coverage ends?
• how the amount you pay for Covered Read the'Termination of Coverage"section.
Services under the BlueCard (Out-of- • what the terms used throughout this
State) Program will be determined when Booklet mean?
you receive care outside the state of Read the"Definitions"section.
Florida?
Read the "BlueCard(Out-of-State) Program"
section.
Overview of How BlueOptions Works
Whenever you need care, you have a choice. If you visit an:
In-Network Provider Out-of-Network Provider
You receive In-Network benefits,the You receive the Out-of-Network level of
highest level of coverage available. benefits—you will share more of the cost of
your care.
You do not have to file a claim; the claim You may be required to submit a claim form.
will be filed by the In-Network Provider for
you.
The In-Network Provider* is responsible You should notify BCBSF of inpatient
for Admission Notification if you are admissions.
admitted to the Hospital.
*For Services rendered by an In-Network Provider located outside of Florida, you should
notify us of inpatient admissions.
How to Use Your Benefit Booklet
1-
Section 2: What Is Covered?
Introduction Necessity coverage criteria then In effect,
except as specified in this section;
This section describes the Health Care Services 4. in accordance with the benefit guidelines
that are covered under this Benefit Booklet. All
benefits for Covered Services are subject to listed below;
your share of the cost and the benefit 5. rendered while your coverage is in force;
maximums listed on your Schedule of Benefits, and
the applicable Allowed Amount, any limitations 6. not specifically or generally limited or
and/or exclusions, as well as other provisions excluded under this Booklet.
contained in this Booklet, and any
Endorsements) in accordance with BCBSF's BCBSF or Monroe County BOCC will determine
Medical Necessity coverage criteria and benefit whether Services are Covered Services under
guidelines then in effect. this Booklet after you have obtained the
Services and a claim has been received for the
Remember that exclusions and limitations also Services. In some circumstances BCBSF or
apply to your coverage. Exclusions and Monroe County BOCC may determine whether
limitations that are specific to a type of Service Services might be Covered Services under this
are included along with the benefit description in this section. Additional exclusions and Booklet before you are provided the Service.
For example, BCBSF or Monroe County BOCC
limitations that may apply can be found in the may determine whether a proposed transplant is
"What Is Not Covered'?"section. More than one a Covered Service under this Booklet before the
limitation or exclusion may apply to a specific transplant is provided. Neither BCBSF nor
Service or a particular situation. Monroe County BOCC are obligated to
Expenses for the Health Care Services listed in determine, in advance, whether any Service not
this section will be covered under this Booklet yet provided to you would be a Covered Service
only if the Services are, unless we have specifically designated that a
Service is subject to a prior authorization
1. within the Health Care Services categories requirement as described in the"Blueprint for
in the"What Is Covered?"section; Health Programs"section. We are also not
2. actually rendered (not just proposed or obligated to cover or pay for any Service that
recommended) by an appropriately licensed has not actually been rendered to,you.
health care Provider who is recognized for In determining whether Health Care Services
payment under this Benefit Booklet and for are Covered Services under this Booklet, no
which an itemized statement or description written or verbal representation by any
of the procedure or Service which was employee or agent of BCBSF or Monroe County
rendered is received, including any BOCC, or by any other person, shall waive or
applicable procedure code, diagnosis code otherwise modify the terms of this Booklet and,
and other information required in order to therefore, neither you„ nor any health care
process a claim for the Service; Provider or other person should rely on any such
3. Medically Necessary, as defined in this written or verbal representation.
Booklet and determined by BCBSF in
accordance with BCBSF's Medical
What Is Covered? 2_1
Our Benefit Guidelines number of tests performed by the Physician.
The Allowed Amount for allergy immunotherapy
In providing benefits for Covered Services, the treatment is based upon the type and number of
benefit guidelines listed below apply as well as doses.
any other applicable payment rules specific to
particular categories of Services: Ambulance Services
1. Payment for certain Health Care Services is Ambulance Services provided by a ground
included within the Allowed Amount for the vehicle may be covered provided it is necessary
primary procedure, and therefore no to transport you from:
additional amount is payable for any such 1. a Hospital which is unable to provide proper
Services.
care to the nearest Hospital that can provide
2. Payment is based on the Allowed Amount proper care;
for the actual Service rendered (i.e., 2. a Hospital to your nearest home, or to a
payment is not based on the Allowed Skilled Nursing Facility; or
Amount for a Service which is more complex
than that actually rendered), and is not 3. the place a medical emergency occurs to
based on the method utilized to perform the the nearest Hospital that can provide proper
Service or the day of the week or the time of care.
day the procedure is performed. Expenses for Ambulance Services by boat,
3. Payment for a Service includes all airplane, or helicopter shall be limited to the
components of the Health Care Service Allowed Amount for a ground vehicle unless:
when the Service can be described by a 1. the pick-up point is inaccessible by ground
single procedure code, or when the Service vehicle;
is an essential or integral part of the
associated therapeutic/diagnostic Service 2. speed in excess of ground vehicle speed is
rendered. critical; or
3. the travel distance involved in getting you to
Covered Services Categories the nearest Hospital that can provide proper
care is too far for medical safety, as
Accident Care determined by BCBSF or Monroe County
Health Care Services to treat an injury or illness BOCC.
resulting from an Accident not related to your job Please refer to your Schedule of Benefits for the
or employment are covered.
per-day maximums for ground transportation
Exclusion: and air/water transportation.
Health Care Services to treat an injury or illness Ambulatory Surgical Centers
resulting from an Accident related to your job or
employment are excluded. Health Care Services rendered at an Ambulatory
Surgical Center are covered and include:
Allergy Testing and Treatments 1. use of operating and recovery rooms;
Testing and desensitization therapy(e.g., 2. respiratory, or inhalation therapy
injections) and the cost of hyposensitization (e.g.,
oxygen);
serum are covered. The Allowed Amount for
allergy testing is based upon the type and
What Is covered?
3. drugs and medicines administered (except 1. well-baby and well-child screening for the
for take home drugs) at the Ambulatory presence of Autism Spectrum Disorder;
Surgical Center;
2. Applied Behavior Analysis, when rendered
4. intravenous solutions; by an individual certified pursuant to Section
5. dressings, including ordinary casts; 393.17 of the Florida Statutes or licensed
6. anesthetics and their administration; under Chapters 490 or 491 of the FloridaStatutes, and
7. administration of, including the cost of, 3. Physical Therapy by a Physical Therapist,
whole blood or blood products(except as Occupational Therapy by an Occupational
outlined in the Drugs exclusion of the'What Therapist, and Speech Therapy by a
Is Not Covered?"section); Speech Therapist. Covered therapies
8. transfusion supplies and equipment; provided in the treatment of Autism
9. diagnostic Services, including radiology, Spectrum Disorder are covered even though
ultrasound, laboratory, pathology and they may be habilitative in nature (provided
approved machine testing (e.g., EKG); and to teach a function)and are not necessarily
limited to restoration of a function or skill that
10. chemotherapy treatment for proven has been lost.
malignant disease.
Payment Guidelines for Autism Spectrum
Anesthesia Administration Services Disorder
Administration of anesthesia by a Physician or The covered therapies provided in the treatment
Certified Registered Nurse Anesthetist("CRNA") of Autism Spectrum Disorder outlined in
may be covered. In those instances where the paragraph three above will be applied to the
CRNA is actively directed by a Physician other Outpatient Therapies Benefit Period maximum
than the Physician who performed the surgical set forth in the Schedule of Benefits. Autism
procedure, payment for Covered Services, if Spectrum Disorder Services must be authorized
any, will be made for both the CRNA and the in accordance with BCBSF's established criteria,
Physician Health Care Services at the lower before such Services are rendered. Services
directed-services Allowed Amount in accordance performed without authorization will be denied.
with BCBSF's payment program then in effect Authorization for coverage is not required when
for such Covered Services. Covered Services are provided for the treatment
Exclusion:
of an Emergency Medical Condition.
Coverage does not include anesthesia Services Exclusion:
by an operating Physician, his or her partner or Any Services for the treatment of Autism
associate. Spectrum Disorder other than as specifically
identified as covered in this section.
Autism Spectrum Disorder Note: In order to determine whether such
Autism Spectrum Disorder Services provided to Autism Spectrum Disorder Services are covered
a Covered Dependent who is under the age of under this Benefit Booklet, we reserve the right
18, or if 18 years of age or older, is attending to request a formal written treatment plan signed
high school and was diagnosed with Autism by the treating Physician to include the
Spectrum Disorder prior to his or her 5th birthday diagnosis, the proposed treatment type, the
consisting of: frequency and duration of treatment, the
What Is Covered? 3
anticipated outcomes stated as goals, and the 1. an In-Network Provider has indicated such
frequency with which the treatment plan will be trial is appropriate for you; or
updated, but no less than every 6 months. This
benefit booklet will only cover services to the 2. you provide us with medical and scientific
extent included in the Treating Physician's information establishing that your
formal written treatment plan. participation in such trial is appropriate.
Breast Reconstructive Surgery Routine patient care includes all Medically
Necessary Services that would otherwise be
Surgery to reestablish symmetry between two covered under this Booklet, such as doctor
breasts and Implanted prostheses incident to visits, lab tests, x-rays and scans and hospital
Mastectomy is covered. In order to be covered, stays related to treatment of your Condition and
such surgery must be provided in a manner is subject to the applicable Cost Share(s)on the
chosen by your Physician, consistent with Schedule of Benefits.
prevailing medical standards, and in consultation
with you. Even though benefits may be available under
this Booklet for routine patient care related to an
Child Cleft Lip and Cleft Palate Treatment Approved Clinical Trial you may not be eligible
for inclusion in these trials or there may not be
Treatment and Services for Child Cleft Lip and any trials available to treat your Condition at the
Cleft Palate, including medical, dental, Speech time you want to be included in a clinical trial.
Therapy, audiology, and nutrition Services for
treatment of a child under the age of 18 who has Exclusion:
cleft lip or cleft palate are covered. In order for 1. Costs that are generally covered by the
such Services to be covered, your Covered clinical trial, including, but not limited to:
Dependent's Physician must specifically a. Research costs related to conducting
prescribe such Services and such Services must the clinical trial such as research
be medically necessary and consequent to Physician and nurse time, analysis of
treatment of the cleft lip or cleft palate. results, and clinical tests performed only
for research purposes.
Clinical Trials b. The investigational item, device or
Clinical trials are research studies in which Service itself.
Physicians and other researchers work to find c. Services inconsistent with widely
ways to improve care. Each study tries to accepted and established standards of
answer scientific questions and to find better care for a particular diagnosis.
ways to prevent, diagnose, or treat patients. 2. Services related to an Approved Clinical
Each trial has a protocol which explains the Trial received outside of the United States.
purpose of the trial, how the trial will be
performed, who may participate in the trial, and Concurrent Physician Care
the beginning and end points of the trial. Concurrent Physician care Services are
If you are eligible to participate in an Approved covered, provided: (a)the additional Physician
Clinical Trial, routine patient care for Services actively participates in your treatment; (b)the
furnished in connection with your participation in Condition involves more than one body system
the Approved Clinical Trial may be covered or is so severe or complex that one Physician
when: cannot provide the care unassisted; and (c)the
What Is Covered?
Physicians
have different specialties ovhave the b) you or your Covered O�an�nh�m
same specialty sub-specialties. Dependent
~ ' one or Conditions that
Consultations would create significant orundue
medical risk for you in the course cf
Consultations provided bya Physician are delivery of any necessary dental
covered if your attending Physician requests the treatment or surgery if not rendered |na
consultation and the consulting Physician Hospital or Ambulatory Surgical Center.
prepares a written report.
Contraceptive Injections 1. Dental Services provided more than 9Odays
Medication by injection ia covered when after the date ofan Accidental Dental Injury
provided and administered bya Physician, for regardless of whether or not such services
the purpose nf contraception, and is limited to could have been rendered within 9Ddays;
the medication and administration when and
medically necessary. Q. Dental Implant.
Dental Services
Dental 8en/iome are limited bn the following: Diabetes Outpatient Self-Management
Diabetes outpatient self-management training
1. Con»and stabilization treatment rendered
and educational Services and nutrition
within g0 days ofan Accidental Dental Injury counseling 0nc|ud|nAaUK8edicaUyNecessary
to Sound Noiume|Teeth. equipment (including
supplies)bo treat diabetes, if
2' Extraction of teeth required prior toradiation your treating Physician ora Physician who
therapy when you have a diagnosis of specializes in the treatment of diabetes certifies
cancer cf the head and/or neck. that such Services are Medically Necessary, are
3. Anesthesia Services for dental care '
covered. |n order tob000verod diabetes
including general anesthesia and outpatient self-management training and
hospitalization 8en/icesnecessary toassure �du��tipnm| 8m'vicewmumtb�provid�� under
the direct supervision ufn certified Diabetes
the safe delivery of necessary dental care Educator ora board-certified Physician
provided to you or your Covered Dependent specializing in endocrinology. 4ddidona||y, in a Hospital ur Ambulatory Surgical Center order to be covered, nutrition counseling mustit
Ue provided bvo licensed Dietitian. Covered
o} the Covered Dependent ie under 8 Services may also include the trimming of
years of age and itim determined bya toenails, corns, calluses, and therapeutic shoes
dentist and the Covered Dependent's (including inserts and/or modifications)for the
Physician that: treatment of severe diabetic foot disease.
i dental treatment|a necessary due to Diagnostic Services
a dental Condition that ie
significantly complex;' or Diagnostic Services when ordered by
Physician are limited bo the following:
ii. the Covered Dependent has a 1. radiology, ultrasound and nuclear medicine
developmental dioob rn Uib/invxh|oh Magnetic Resonance Imaging �Kx�|1' '
patient �n���nnmntin the dental
` ''
office has proven tobeineffective; 2' laboratory and pathology Services;
or
What mCovered?
3. Services involvingbones joints
or 1 of the law Note: Repair or replacement of Durable
(e.g., Services to treat temporomandibular Medical Equipment due to growth of a child or
joint[TMJ] dysfunction) or facial region if, significant change in functional status is a
under accepted medical standards, such Covered Service.
diagnostic Services are necessary to treat
Conditions caused by congenital or Exclusion:
developmental deformity, disease, or injury; Equipment which is primarily for convenience
4. approved machine testing (e.g., and/or comfort; modifications to motor vehicles
electrocardiogram [EKG], and/or homes, including but not limited to,
electroencephalograph [EEG], and other wheelchair lifts or ramps; water therapy devices
electronic diagnostic medical procedures); such as Jacuzzis, hot tubs, swimming pools or
and whirlpools; exercise and massage equipment,
electric scooters, hearing aids, air conditioners
5. genetic testing for the purposes of and purifiers, humidifiers, water softeners and/or
explaining current signs and symptoms of a purifiers, pillows, mattresses or waterbeds,
possible hereditary disease. escalators, elevators, stair glides, emergency
alert equipment, handrails and grab bars, heat
Dialysis Services appliances, dehumidifiers, and the replacement
Dialysis Services including equipment, training, of Durable Medical Equipment solely because it
and medical supplies, when provided at any is old or used are excluded.
location by a Provider licensed to perform
dialysis including a Dialysis Center are covered. Emergency Services
Emergency Services for an Emergency Medical
Durable Medical Equipment Condition are covered when rendered In-
Durable Medical Equipment when provided by a Network and Out-of-Network without the need
Durable Medical Equipment Provider and when for any prior authorization determination by us.
prescribed by a Physician, limited to the most
cast-effective equipment as determined by When Emergency Services and care for an
BCBSF or Monroe County BOCC is covered. Emergency Medical Condition are rendered by
an Out-of-Network Provider, any Copayment
Payment Guidelines for Durable Medical and/or Coinsurance amount applicable to In-
Eaulpment Network Providers for Emergency Services will
Supplies and service to repair medical also apply to such Out-of-Network Provider.
equipment may be Covered Services only if you Special Payment Rules for Non-Grandfathered
own the equipment or you are purchasing the Plans
equipment. Payment for Durable Medical The Patient Protection and Affordable Care Act
Equipment will be based on the lowest of the (PPACA) requires that non-grandfathered health
following: 1)the purchase price; 2)the plans apply a specific method for determining
lease/purchase price; 3)the rental rate; or 4)the the allowed amount for Emergency Services
Allowed Amount. The Allowed Amount for such rendered for an Emergency Medical Condition
rental equipment will not exceed the total by Providers who do not have a contract with us.
purchase price. Durable Medical Equipment Payment for Emergency Services rendered by
includes, but is not limited to, the following: an Out-of-Network Provider that has not entered
wheelchairs, crutches, canes, walkers, hospital into an agreement with BCBSF to provide
beds, and oxygen equipment.
What Is covered?
2
access to a discount from the billed amount of surgical procedure performed primarily to correct
that Provider will be the greater of: or improve myopia or other refractive disorders
1. the amount equal to the median amount (e.g., radial keratotomy, PRK and LASIK) are
negotiated with all BCBSF In-Network excluded.
Providers for the same Services;
2. the Allowed Amount as defined in the Home Health Care
Booklet; or
The Home Health Care Services listed below
3. what Medicare would have paid for the are covered when the following criteria are met:
Services rendered.
1. you are unable to leave your home without
In no event will Out-of-Network Providers be considerable effort and the assistance of
paid more than their charges for the Services another person because you are: bedridden
rendered. or chairbound or because you are restricted
Enteral Formulas in ambulation whether or not you use
assistive devices; or you are significantly
Prescription and non-prescription enteral limited in physical activities due to a
formulas for home use when prescribed by a Condition; and
Physician as necessary to treat inherited 2. the Home Health Care Services rendered
diseases of amino acid, organic acid, have been prescribed by a Physician by way
carbohydrate or fat metabolism as well as of a formal written treatment plan that has
malabsorption originating from congenital been reviewed and renewed by the
defects present at birth or acquired during the
prescribing Physician every 30 days. In
neonatal period are covered. order to determine whether such Services
Coverage to treat inherited diseases of amino are covered under this Booklet, you may be
acid and organic acids, for you up to your 25th required to provide a copy of any written
birthday, shall include coverage for food treatment plan;
products modified to be low protein. 3. the Home Health Care Services are
Eye Care provided directly by(or indirectly through) a
Coverage includes the following Services: Home Health Agency; and
4. you are meeting or achieving the desired
1. Physician Services, soft lenses or sclera treatment goals set forth in the treatment
shells, for the treatment of aphakic patients; plan as documented in the clinical progress
2. initial glasses or contact lenses following notes.
cataract surgery; and Home Health Care Services are limited to:
3. Physician Services to treat an injury to or 1. part-time (i.e., less than 8 hours per day and
disease of the eyes. less than a total of 40 hours in a calendar
Exclusion: week) or intermittent(i.e., a visit of up to, but
not exceeding, 2 hours per day) nursing
Health Care Services to diagnose or treat vision care by a Registered Nurse, Licensed
problems which are not a direct consequence of Practical Nurse and/or home health aide
trauma or prior ophthalmic surgery; eye Services;
examinations; eye exercises or visual training;
eye glasses and contact lenses and their fitting 2. home health aide Services must be
are excluded. In addition to the above, any consistent with the plan of treatment,
What Is Covered? ?
ordered by a Physician, and rendered under Hospital Services
| the muponiok�nof� m�d �ur���
. - Covered Hospital Services include:
3. medical social
1. room and board inm semi-private room
4. nutritional guidance; when confined aoan inpatient, unless the
5' 'espiratory, mr inhalation therapy(e.�., patient must be isolated from others for
� ooumonte�n|ini |
o�yg�n)| ond � oo namoono|
G' Physical Therapy bva Physical Therapist, 2' intensive care units, including cardiac,
Occupational Therapy byoOccupational progressive and neonatal care;
Therapist, and Speech Therapy bya 3' use nf operating and recovery rooms;
Speech Therapist.
4. use of emergency rooms;
Exclusions-
5. respiratory, pulmonary, or inhalation therapy
1. homemaker or domestic maid services; (e.g., oxygen);
2. sifter or companion services; 6' drugs and medicines administered (except
3' Services rendered byan employee or for take home drugs) by the Hospital;
operator ofan adult congregate living 7' intravenous solutions;
facility; an adult foster home; an adult day B. administration of, including the cost of,
care center, oro nursing home facility, whole blood or blood products except as
4' Speech Therapy provided for a diagnosis of outlined in the Drugs exclusion ofthe"Vyhot
developmental delay; |o Not Coverad?"aootion);
5' Custodial Care except for any such care 9' dressings, including ordinary casts;
covered under this subsection when 10' anesthetics and their administration;
provided ono part-time or intermittent basis 11. transfusion supplies and equipment;
(as defined above) by a home health aide;
8. food, housing, andhom�do|�anodm�e|o. 12' diagnostic Sendcee, including radiology,
, ' ultrasound, laboratory, pathology and
and
approved machine testing (o.g.. EKG);
7. Services rendered ina Hospital, nursing 13. Physical, Speech, Occupational, and
homa, or intermediate care facility. Cardiac Therapies; and
Hospice Services 14. transplants aa described in the Transplant
Health Care Services provided inconnection Services subsection.
with s Hospice treatment program may bo Exclusion:
Covered Services, provided the Hospice Expenses for the following Hospital Services are
treatment program is: excluded when such Services could have been
1' approved by your Physician; and provided without admitting you to the Hospital:
1) room and board provided during the
2. your doctor has certified toueinwriting that admission; 2) Physician visits provided while you
your life expectancy is12months or less. were aninpatient; 3> Occupational Therapy,
Recertification im required every six months. Speech Therapy, Physical Therapy, and Cardiac
What wCovered?
o-8
Therapy; and 4)other Services provided while Exclusion:
you were an inpatient.
All Substance Dependency, drug and alcohol
In addition, expenses for the following and related diagnoses, Pain Management, and
similar items are also excluded: respiratory ventilator management Services are
1. gowns and slippers; excluded.
2. shampoo, toothpaste, body lotions and Mammograms
hygiene packets;
Mammograms obtained in a medical office,
3. take-home drugs; medical treatment facility or through a health
4. telephone and television; testing service that uses radiological equipment
5. guest meals or gourmet menus; and
registered with the appropriate Florida regulatory
agencies (or those of another state)for
6. admission kits. diagnostic purposes or breast cancer screening
are Covered Services.
Inpatient Rehabilitation Benefits for mammograms may not be subject to
Inpatient Rehabilitation Services are covered the Deductible, Coinsurance, or Copayment(if
when the following criteria are met: applicable). Please refer to your Schedule of
1. Services must be provided under the Benefits for more information.
direction of a Physician and must be Mastectomy Services
provided by a Medicare certified facility in
accordance with a comprehensive Breast cancer treatment including treatment for
rehabilitation program; physical complications relating to a Mastectomy
2. a plan of care must be developed and (including lymphedemas), and outpatient post-
managed by a coordinated multi-disciplinary surgical follow-up in accordance with prevailing
team; medical standards as determined by you and
your attending Physician are covered.
3. coverage is subject to our Medical Necessity Outpatient post-surgical follow-up care for
coverage criteria then in effect; Mastectomy Services shall be covered when
4. the individual must be able to actively provided by a Provider in accordance with the
participate in at least 2 rehabilitative prevailing medical standards and at the most
therapies and be able to tolerate at least 3 medically appropriate setting. The setting may
hours per day of skilled Rehabilitation be the Hospital, Physician's office, outpatient
Services for at least 5 days a week and their center, or your home. The treating Physician,
Condition must be likely to result in after consultation with you, may choose the
significant improvement; and appropriate setting.
5. the Rehabilitation Services must be required Maternity Services
at such intensity,frequency and duration
that further progress cannot be achieved in Health Care Services, including prenatal care,
delivery and postpartum care and assessment,
a less intensive setting. provided to you, by a Doctor of Medicine (M.D.),
Inpatient Rehabilitation Services are subject to Doctor of Osteopathy(D.O.), Hospital, Birth
the inpatient facility Copayment, if applicable, Center, Midwife or Certified Nurse Midwife may
and the benefit maximum set forth in the be Covered Services. Care for the mother
Schedule of Benefits. includes the postpartum assessment.
What Is Covered?
2-B
' In order for the postpartum assessment to be The Medical Pharmacy Cost Share amount
covered, such assessment must be provided at apo|iemto the Pnaocdpdon []muQand does not
a Hospital, an attending Physician's office, an includeapplies to
administration of the Prescription
outpatient maternity center, mrin the home byo Drug.
qualified licensed health care professional
trained in care for amother. Coverage under Your plan may also include annaximunn monthly
this Booklet for the postpartum assessment amount you will ba required to pay out-of-ponket
includes coverage for the physical assessment for Medical Pharmacy, when such Services are
of the mother and any necessary clinical tests in provided byen |n'Nmbmork Provider orSpecialty
keeping with prevailing medical standards. Pharmacy. |f your plan includes oMedical
Under Federal law, your Group Plan generally Pharmacy out-of-ponkmt monthly maximum, |t
may not restrict benefits for any hospital length will be listed on your Schedule of Benefits and
pf stay in connection with childbirth for the only applies after you have met your Deductible,
mother or newborn child bz less than 48hours if applicable.
following a vaginal delivery; or less than 96 Please refer to your Schedule of Benefits for the
hours following a cesarean section. However, additional Cost Share amount and/or monthly
Federal law generally does not prohibit the maximum Put-of-pochet applicable toMedical
mother's or newborn's attending Provider, after Pharmacy for your plan.
consulting with the mother,from discharging the
mother or her newborn eadiarthan 4B hours(or ��8�: Fo'PurPoamoofthiab�naf�. eUergV
injections
96as applicable). |n any case, under Federal andimmuni�mtonaar� ncdoonn|denmd
law, your Group Plan can only require that a Medical Pharmacy.
provider obtain authorization for prescribing an
inpatient hospital stay that exceeds 48 hours (or
0Y���mU ��myt� �wm�U�em
OGhouna). Diagnostic evaluation, psychiatric treatment,
individual therapy, and group therapy rendered
tm you bya Physician, Psychologist orMental
Maternity Services rendered hoaCovered Health Professional for the treatment ofoMental
Person who becomes pregnant as aBeotationa| and Nervous Disorder may becovered.
Surrogate under the terms of, and inaccordance Covered Services may include:
with, a Gestational Surrogacy Contract or 1. Physician office visits;
Arrangement are excluded. This exclusion
applies to all expenses for prenatal, in1na'pa�a|. �' Intensive CJutpo1iont�r����/�nt�ean��r�� in
and pws�pada| K8a1ornity/Obmtmtdna| (�ara. and
�hsniUbd' oedefin�dinthie �ooWot| end
Health Care Services rendered to the Covered 3. Partial Hospitalization, oe defined |nthis
Person acting maa Gestational Surrogate. Booklet, when provided under the direction
For the definition of Gestational Surrogate and of Physician.
Gestational Surrogacy Contract, see the
"Oafinitions'section of this Benefit Booklet. ��-
1. Services rendered for a Condition that isnot
Medical Pharmacy a Mental and Nervous Disorder aa defined in
this Booklet, regardless of the underlying
Physician-administered Prescription Drugs cause, or effect, of the dieondoc
which are rendered ina Physician's office are '
subject toa separate Cost Share amount that is �' ��n/ic��ƒorpoY�ho|og|u�|teetimQ
in add�|onto1hoo�ioovimit<�ootGh�naammunt. associated wdhthe eva|uadonand diagnosis
What IsCovered?
of learning disabilities or intellectual standards. These Services are not subject to
disability; the Deductible.
3. Services beyond the period necessary for Ambulance Services, when necessary to
evaluation and diagnosis of learning transport the newborn child to and from the
disabilities or intellectual disability; nearest appropriate facility which is staffed and
4. Services for marriage counseling unless equipped to treat the newborn child's Condition,
related to a Mental and Nervous Disorder as as determined by BCBSF or Monroe County
defined in this Booklet, regardless of the BOCC and certified by the attending Physician
underlying cause, or effect, of the disorder; as Medically Necessary to protect the health and
safety of the newborn child, are covered.
5. Services for pre-marital counseling;
6. Services for court-ordered care or testing, or Under Federal law, your Group Plan generally
required as a condition of parole or may not restrict benefits for any hospital length
probation; of stay in connection with childbirth for the
mother or newborn child to less than 48 hours
7. Services for testing of aptitude, ability, following a vaginal delivery; or less than 96
intelligence or interest(except as covered hours following a cesarean section. However,
under the Autism Spectrum Disorder Federal law generally does not prohibit the
subsection); mother's or newborn's attending Provider, after
8. Services for testing and evaluation for the consulting with the mother, from discharging the
purpose of maintaining employment; mother or her newborn earlier than 48 hours (or
9. Services for cognitive remediation; 96 as applicable). In any case, under Federal
law, your Group Plan can only require that a
10. inpatient confinements that are primarily provider obtain authorization for prescribing an
intended as a change of environment; or inpatient hospital stay that exceeds 48 hours (or
11. inpatient(over night) mental health Services 96 hours).
received in a residential treatment facility.
Orthotic Devices
Newborn Care
Orthotic Devices including braces and trusses
A newborn child will be covered from the for the leg, arm, neck and back, and special
moment of birth provided that the newborn child surgical corsets are covered when prescribed by
Is eligible for coverage and properly enrolled. a Physician and designed and fitted by an
Covered Services shall consist of coverage for Orthotist.
injury or sickness, including the necessary care
or treatment of medically diagnosed congenital Benefits may be provided for necessary
replacement of an Orthotic Device which is
defects, birth abnormalities, and premature birth.
owned by you when due to irreparable damage,
Newborn Assessment: wear, a change in your Condition, or when
An assessment of the newborn child is covered necessitated due to growth of a child.
provided the Services were rendered at a Payment for splints for the treatment of
Hospital, the attending Physician's office, a Birth temporomandibular joint('TMX) dysfunction is
Center, or in the home by a Physician, Midwife limited to payment for one splint in a six-month
or Certified Nurse Midwife, and the performance period unless a more frequent replacement is
of any necessary clinical tests and determined by BCBSF or Monroe County BOCC
immunizations are within prevailing medical to be Medically Necessary.
What Is Covered?
2'-t�
Exclusion: Outpatient Cardiac, Occupational, Physical,
1. Expenses for arch supports, shoe inserts Speech, Massage Therapies and Spinal
designed to effect conformational changes Manipulation Services
in the foot or foot alignment, orthopedic Outpatient therapies listed below may be
shoes, over-the-counter, custom-made or Covered Services when ordered by a Physician
built-up shoes, cast shoes, sneakers, ready- or other health care professional licensed to
made compression hose or support hose, or perform such Services. The outpatient therapies
similar type devices/appliances regardless listed in this category are in addition to the
of intended use, except for therapeutic Cardiac, Occupational, Physical and Speech
shoes (including inserts and/or Therapy benefits listed In the Home Health
modifications)for the treatment of severe Care, Hospital, and Skilled Nursing Facility
diabetic foot disease; categories herein.
2. Expenses for orthotic appliances or devices Cardiac Therapy Services provided under the
which straighten or re-shape the supervision of a Physician, or an appropriate
conformation of the head or bones of the Provider trained for Cardiac Therapy, for the
skull or cranium through cranial banding or purpose of aiding in the restoration of normal
molding (e.g. dynamic orthotic cranioplasty heart function in connection with a myocardial
or molding helmets), except when the infarction, coronary occlusion or coronary
orthotic appliance or device is used as an bypass surgery are covered.
alternative to an internal fixation device as a
result of surgery for craniosynostosis; and Occupational Therapy Services provided by a
Physician or Occupational Therapist for the
3. Expenses for devices necessary to exercise, purpose of aiding in the restoration of a
train, or participate in sports, e.g. custom- previously impaired function lost due to a
made knee braces. Condition are covered.
Osteoporosis Screening, Diagnosis, and Speech Therapy Services of a Physician,
Treatment Speech Therapist, or licensed audiologist to aid
Screening, diagnosis, and treatment of in the restoration of speech loss or an
impairment of speech resulting from a Condition
osteoporosis for high-risk individuals is covered
as medically necessary, including, but not are covered.
limited to: Physical Therapy Services provided by a
Physician or Physical Therapist for the purpose
1. estrogen-deficient individuals who are at of aiding in the restoration of normal physical
clinical risk for osteoporosis; function lost due to a Condition are covered.
2. individuals who have vertebral Massage Therapy Massage provided by a
abnormalities; Physician, Massage Therapist, or Physical
3. individuals who are receiving long-term Therapist when the Massage is prescribed as
glucocorticoid (steroid)therapy; or being Medically Necessary by a Physician
4. individuals who have primary licensed pursuant to Florida Statutes Chapter
hyperparathyroidism, and 458(Medical Practice), Chapter 459
(Osteopathy), Chapter 460(Chiropractic) or
5. individuals who have a family history of Chapter 461 (Podiatry) is covered. The
osteoporosis. Physician's prescription must specify the
number of treatments.
What is covered?
2-12
Payment Guldellnes for Massage and therapies
and spinal manipulation Services
Physical Therapy listed above. For example, even if you may
1. Payment for covered Massage Services is have only been administered two(2)of the
limited tmno more than four(4) 15'minute spinal manipulations for the Benefit Period, any
Massage treatments per day, not boexceed additional spinal manipulations for that Benefit
the Outpatient Cardiac, Occupational, Period will not be covered if you have already
Physical, Speech, and Massage Therapies met the combined therapy visit maximum with
and Spinal Manipulations benefit maximum other Services.
listed on the Schedule ofBenefits
. Oxygen
2. Payment for a combination ofcovered
Expenses for oxYQen. the equipment nocemoary
0Nommagoand Physical Therapy Sen/ioao
nsndonadontheoennedayiaUm|t�dtono to administer it, and the adnn|niatratonofoxygen
are covenmd
mnonathan four�) 15'minutetreadments per '
day for combined Massage and Physical Physician Services
Therapy treatment, not bo exceed the
Outpatient Cardiac, Occupational, Physical, K8ad|oa| or surgical Health Care Gmnvioem
Speech, and Massage Therapies and Spinal provided bya Physician, including Services
Manipulations benefit maximum listed onthe rendered in the Physician's office, inan
Schedule ofBenefits. outpatient facility, or electronically through a
3. Payment for covered Physical Therapy computer via the Internet.
Services rendered on the same day em Payment-Guidelines for Physician services
spinal manipulation is limited boone (1) Provided by Electronic Means throuah a
Physical Therapy treatment per day not bo
exceed fifteen (15) minutes inlength. --------
Expenses for online medical Services provided
Spinal Manipulations: Services bvPhysicians electronically through a computer bVaPhysician
for manipulations of the spine to correct aslight via the Internet will bo covered only ifsuch
dislocation ofa bone nr joint that is Services:
demonstrated by x-ray are covered.
Payment Guidelines for Spinal Manipulation 1. were provided toocovered individual who
was, cd the time the Services were provided,
i' Payment for covered spinal manipulation is on established patient of the Physician
limited tono more than 8Gspinal rendering the Services;
manipulations per Benefit Period, orthe Q. were in response toan online inquiry
maximum benefit listed in the Schedule of received through the Internet from the
Benefits, whichever ' covered individual with respect towhich the
2' Payment for covered Physical Therapy Services were provided; and
Services rendered on the same day asa 8. were provided bya Physician through a
spinal manipulation in limited toone (1�
` ' secure online healthcare communication
Physical Therapy treatment per day, not to services vendor that, cd the time the
exceed fifteen (16) minutes inlength. Services were rendered, was under contract
Your Schedule of Benefits sets forth the wdhBCB8F.
maximum number of visits covered under this The term"established pat|ent."an used herein
plan for any combination of the outpatient shall '
U
What/oCovered?
u'm
received professional services from the 3. with respect to infants, children, and
Physician who provided the online medical adolescents, evidence-informed preventive
Services, or another physician of the same care and screenings provided for in the
specialty who belongs to the same group comprehensive guidelines supported by the
practice as that Physician, within the past three Health Resources and Services
years.
Administration; and
Exclusion: 4. with respect to women, such additional
Expenses for online medical Services provided preventive care and screenings not
electronically through a computer by a Physician described in paragraph number one as
via the Internet other than through a healthcare provided for in comprehensive guidelines
communication services vendor that has entered supported by the Health Resources and
into contract with BCBSF are excluded. Services Administration. Women's
Expenses for online medical Services provided preventive coverage under this category
by a health care provider that is not a Physician includes:
and expenses for Health Care Services a. well-woman visits;
rendered by telephone are also excluded.
b. screening for gestational diabetes;
Preventive Health Services c. human papillomavirus testing;
Preventive Services are covered for both adults d. counseling for sexually transmitted
and children based on prevailing medical infections;
standards and recommendations which are
explained further below. Some examples of e• counseling and screening for human
preventive health Services include, but are not immune-deficiency virus;
limited to, periodic routine health exams, routine f. contraceptive methods and counseling;
gynecological exams, immunizations and related
preventive Services such as Prostate Specific g• screening and counseling for
Antigen (PSA), routine mammograms and pap interpersonal and domestic violence;
smears. In order to be covered, Services shall and
be provided in accordance with prevailing h. breastfeeding support, supplies and
medical standards consistent with: counseling. Breastfeeding supplies are
1. evidence-based items or Services that have limited to one manual breast pump per
in effect a rating of'A'or'B' in the current pregnancy.
recommendations of the U.S. Preventive Exclusion:
Services Task Force established under the Routine vision and hearing examinations and
Public Health Service Act; screenings are not covered as Preventive Health
2. immunizations that have in effect a Services, except as required under paragraph
recommendation from the Advisory number one and/or number three above.
Committee on Immunization Practices of the Sterilization procedures covered under this
Centers for Disease Control and Prevention category are limited to tubal ligations only.
established under the Public Health Service Contraceptive implants are limited to Intra-
Act with respect to the individual involved; uterine devices (IUD) indicated as covered in the
Medication Guide only, including insertion and
removal.
What Is Covered?
2-14
Prosthetic Devices symbol in the Medication Guide when
The following Prosthetic Devices are covered delivered to you at home and purchased at a
when prescribed by a Physician and designed Specialty Pharmacy or an Out-of-Network
and fitted by a Prosthetist: Provider that provides Specialty Drugs.
1. artificial hands, arms, feet, legs and eyes, 3. Specialty Drugs used to increase height or
including permanent implanted lenses bone growth (e.g., growth hormone), must
following cataract surgery, cardiac meet the following criteria in order to be
pacemakers, and prosthetic devices incident covered:
to a Mastectomy; a. Must be prescribed for Conditions of
2. appliances needed to effectively use artificial growth hormone deficiency documented
limbs or corrective braces; or with two abnormally low stimulation
3. penile prosthesis, tests of less than 10 ng/ml and one
Covered Prosthetic Devices (except cardiac abnormally low growth hormone
pacemakers, and Prosthetic Devices incident to dependent peptide or for Conditions of
Mastectomy) are limited to the first such growth hormone deficiency associated
permanent prosthesis(including the first with loss of pituitary function due to
temporary prosthesis if it is determined to be trauma, surgery, tumors, radiation or
necessary) prescribed for each specific disease, or for state mandated use as in
Condition. patients with AIDS.
Benefits may be provided for necessary b. Continuation of growth hormone therapy
replacement of a Prosthetic Device which is is only covered for Conditions
owned by you when due to irreparable damage, associated with significant growth
wear, or a change in your Condition, or when hormone deficiency when there Is
necessitated due to growth of a child. evidence of continued responsiveness
to treatment. Treatment is considered
9KC-IUSiory responsive in children less than 21 '
1. Expenses for microprocessor controlled or years of age, when the growth hormone
myoelectric artificial limbs(e.g. C-legs); and dependent peptide (IGF-1) is in the
normal range for age and Tanner
2. Expenses for cosmetic enhancements to development stage; the growth velocity
artificial limbs. is at least 2 orn per year, and studies
Self-Administered Prescription Drugs demonstrate open epiphyses.
Treatment is considered responsive in
The following Self-Administered Drugs are both adolescents with closed epiphyses
covered: and for adults, who continue to evidence
1. Self-Administered Prescription Drugs used growth hormone deficiency and the IGF-
in the treatment of diabetes, cancer, 1 remains in the normal range for age
Conditions requiring immediate stabilization and gender.
(e.g. anaphylaxis), or in the administration of Skilled Nursing Facilities
dialysis; and
The following Health Care Services may be
2. Self-Administered Prescription Drugs Covered Services when you are an inpatient in a
identified as Specialty Drugs with a special Skilled Nursing Facility:
What is covered?
2-15
t room and bo�rd_-, state)for Detoxification orSubstance
2. respiratory, pulmonary, or inhalation therapy Dependency,
(e.g.. oxygen); Q. Phyo|nion, Psychologist and K8wnba| Health
' 3' drugs and medicines administered while an Professional outpatient visits for the care
inpatient(except take home drugs1| and treatment of Substance Dependency.
4. intravenous solutions;'
5. administration of, including the cost of, Expenses for prolonged care and treatment of
whole blood or blood pnoducts(axcoptas Substance Dependency inaspecialized
outlined |n the Drugs exclusion mf the 'What inpatient or residential facility orinpatient
|a Not Covomed?"omntion); confinements that are primarily intended es a
6' dressings, including ordinary casts; change of environment are excluded.
7' transfusion supplies and equipment; Surgical Assistant Services
@. diagnostic Services, including radiology, Somi000 rendered by Phymioian. Registered
ultrasound, laboratory, pathology and Nurse First Assistant or Physician Assistant
approved machine testing (a.g.. EKG); when acting as surgical assistant(provided no
B' chemotherapy treatment for proven Intern, resident, pr other staff physician |a
malignant disease; and available)when the assistant ie necessary are
covered.
10. Physical, Speech, and Occupational
Surgical Pmmomd�«w�
Therapies.
A treatment plan from your Physician may be Surgical procedures performed byoPhysician
required in order to determine coverage and may bm covered including the following:
payment. I. sterilization (tuba| U0sd|mnaand
vooentomiaa), regardless ofK8edina|
____ Nanooady|
Expenses for an inpatient admission toaSkilled
Nursing Fac|Ub/for purposes oy<�uatodia| Cana �' aur���yt000noutd�formbxwh|oh �ao
omnm�e�oontoone. oranycdherSen/ioa ' caused by disease, tnaumma. bi�hdefects,
primarily for the convenience of you and/or your growth defects or prior thmnspaubc
processes;
family members or the Provider are excluded.
3. oral ou,Q|co| procedures for excisions of
Substance Dependency Care and Treatment tumors, cysts, abscesses, and lesions mfthe
Care and treatment for Substance Dependency mouth;
includes the following: 4. surgical procedures involving bones o,jo|nts
1' Health Care 8arv|nea (inpatient and of the jaw(e.g., temporonnandibu|arjo|nt
outpatient orany combination themaoU �lNJ]\and facial region if, under accepted
provided bya Physician, Psychologist
'or medical standards, such surgery|o
Mental Health Professional inaprogram necessary h»treat Conditions caused bv
accredited by the Joint Commission onthe congenital o'developmental deformity,
Accreditation of Healthcare Organizations or dimaaoo' or injury;
approved by the state of Florida(or another 5' Services ofe Physician for the purpose of
rendering a second surgical opinion and
What wCovered?
related diagnostic services to help determine 2. Payment for incidental surgical procedures
the need for surgery; and is limited to the Allowed Amount for the
6. surgical procedures performed on a Covered primary procedure, and there is no
Plan Participant for the treatment of Morbid additional payment for any incidental
Obesity(e.g., intestinal bypass, stomach procedure. An "Incidental surgical
stapling, balloon dilation) and the associated procedure"includes surgery where one, or
care provided the Covered Plan Participant more than one, surgical procedure is
has not previously undergone the same or performed through the same incision or
similar procedure in the lifetime of this operative approach as the primary surgical
Group Health Plan when medically procedure which, in BCBSFs or Monroe
necessary. County BOCC's opinion, is not clearly
Exclusion: identified and/or does not add significant
time or complexity to the surgical session.
a. Surgical procedures for the treatment of For example, the removal of a normal
Morbid Obesity including: intestinal appendix performed in conjunction with a
bypass; stomach stapling; balloon Medically Necessary hysterectomy is an
dilation and associated care for the incidental surgical procedure (i.e., there is
surgical treatment of Morbid Obesity, if no payment for the removal of the normal
the Covered Plan Participant has appendix in the example).
previously undergone the same or 3. Payment for surgical procedures for fracture
similar procedures in the lifetime of this
Group Health Plan. Surgical procedures cars, dislocation treatment, debridement,
performed to revise, or correct defects wound repair, unna boot, and other related
related to, a prior intestinal bypass, Health Care Services, is included in the
stomach stapling or balloon dilation are Allowed Amount of the surgical procedure.
also excluded. Transplant Services
b. Reversal of a weight loss surgery, Transplant Services, limited to the procedures
surgical procedures to revise, correct, listed below, may be covered when performed at
and correction of defects to include a facility acceptable to BCBSF or Monroe
adjustment to devices Implanted or any County BOCC, subject to the conditions and
fills not performed during the initial surgical event. limitations described below.
Payment Guidelines for Surgical Procedures Transplant includes pre-transplant,transplant
and post-discharge Services, and treatment of
1. Payment for multiple surgical procedures complications after transplantation. Benefits will
performed in addition to the primary surgical only be paid for Services, care and treatment
procedure, on the same or different areas of received or provided in connection with a:
the body, during the same operative session 1. Bone Marrow Transplant, as defined herein,
will be based on 50 percent of the Allowed which is specifically listed in the rule 598-
procedure(s) performed. In addition,Amount for any secondary surgical 12.001 of the Florida Administrative Code or
Coinsurance or Copayment(if any) indicated any successor or similar rule or covered by
in your Schedule of Benefits will apply. This Medicare as described in the most recently
guideline is applicable to all bilateral published Medicare Coverage Issues
procedures and all surgical procedures Manual issued by the Centers for Medicare
performed on the same date of service. and Medicaid Services. Coverage will be
What is Covered?
2-17
provided for the expenses incurred for the
donation of bone marrow by a donor bnthe
same extent such expenses would be
covered for you and will bo subject b»the
| same limitations and exclusions aa would bo
applicable toyou. Coverage for the
reasonable expenses of searching for the
donor will bo limited bze search among
immediate family members and donors
identified through the National Bone Marrow
Donor Program;
Q. corneal transplant;
3. heart transplant(including awantdcular
assist device, if indicated, when used aoa
bridge bo heart tnanap|amtabon)|
4. heart-lung combination transplant;
S. liver transplant;
8. kidney transplant;
x. pancreas;
u. pancreas transplant performed
simultaneously with o kidney transplant; or
9. |umg'who|ea|ng!e or whole bilateral
transplant.
Coverage will be provided for donor costs and
organ acquisition for transplants, other than
Bone Marrow Transplants, provided such costs
are not covered in whole orin part bv any other
insurance carrier, organization or person other
than the donors family or estate.
You may call the customer service phone
number indicated in this Booklet oronyour
Identification Card in order todetermine which
Bone Marrow Transplants are covered under
this Booklet.
What|uCovered?
m10
Exclusions:
Expenses for the following are excluded:
1. transplant procedures not included in the list
above, or otherwise excluded under this
Booklet(e.g., Experimental or Investigational
transplant procedures);
2. transplant procedures involving the
transplantation or implantation of any non-
human organ or tissue;
3. transplant procedures related to the donation
or acquisition of an organ or tissue for a
recipient who is not covered under this
Benefit Booklet;
4. transplant procedures involving the implant of
an artificial organ, including the implant of the
artificial organ;
5. any organ, tissue, marrow, or stem cells
which is/are sold rather than donated;
& any Bone Marrow Transplant, as defined
herein, which is not specifically listed in rule
59B-12.001 of the Florida Administrative
Code or any successor or similar rule or
covered by Medicare pursuant to a national
coverage decision made by the Centers for
Medicare and Medicaid Services as
evidenced In the most recently published
Medicare Coverage Issues Manual;
7. any Service in connection with the
identification of a donor from a local, state or
national listing, except in the case of a Bone
Marrow Transplant;
8. any non-medical costs, including but not
limited to,temporary lodging or transportation
costs for you and/or your family to and from
the approved facility; and
9. any artificial heart or mechanical device that
replaces either the atrium and/or the
ventricle.
What Is Conrad?
2-19
A
Section 3: What Is Not Covered?
Introduction clinical ecology; chelation therapy;
thermography; mind-body interactions such as
Your Booklet expressly excludes expenses for meditation, imagery, yoga, dance, and art
the following Health Care Services, supplies„ therapy; biofeedback; prayer and mental
drugs or charges. The following exclusions are healing; manual healing methods such as the
in addition to any exclusions specified in the Alexander technique, aromatherapy, Ayurvedic
"What Is Covered?"section or any other section massage, craniosacral balancing, Feldenkrais
of the Booklet. method, Hellerwork, polarity therapy, Relchian
Abortions which are elective. therapy, reflexology, rolfing, shiatsu, traditional
Chinese massage, Trager therapy, trigger-point
Arch Supports,shoe inserts designed to effect myotherapy, and biofield therapeutics; Reiki,
conformational changes in the foot or foot SHEN therapy, and therapeutic touch;
alignment„ orthopedic shoes, over-the-counter, bloeiectromagnetic applications in medicine; and
custom-made or built-up shoes, cast shoes, herbal therapies.
sneakers, ready-made compression hose or
support hose, or similar type devices/appliances Complications of Non-Covered Services,
regardless of intended use, except for including the diagnosis or treatment of any
therapeutic shoes(including inserts and/or Condition which Is a complication of a non-
modifications)for the treatment of severe covered Health Care Service (e.g., Health Care
diabetic foot disease. Services to treat a complication of cosmetic
Assisted Reproductive Therapy(Infertility) surgery are not covered).
including, but not limited to, associated Services, Contraceptive medications,devices,
supplies, and medications for In Vitro appliances, or other Health Care Services when
Fertilization (IVF); Gamete intrafallopian provided fair contraception, except when
Transfer(GIFT) procedures; Zygote indicated as covered, under the Preventive
Intrafallopian Transfer(ZIFT) procedures; Health Services category of the "What Is
Artificial Insemination (AI); embryo transport; Covered?"section.
surrogate parenting; donor semen and related Cosmetic Services, including any Service to
costs including collection and preparation; and improve the appearance or self-perception of an
infertility treatment medication. individual (except as covered under the Breast
Autopsy or postmortem examination services, Reconstructive Surgery category), including and
unless specifically requested by BCBSF or 'without limitation: cosmetic surgery and
Monroe County BOCC. procedures or supplies to correct hair loss or
skin wrinkling (e.g., Minoxidil, Rogaine, Retin-A),
Complementary or Alternative Medicine and hair implants/transplants.
Including, but not limited to, self-care or self-help
training; homeopathic medicine and counseling; Costs related to telephone consultations, failure
Ayurvedic medicine such as lifestyle to keep a scheduled appointment, or completion
modifications and purification therapies; of any form and/or medical information.
traditional Oriental medicine including Custodial Care and any service of a custodial
acupuncture; naturopathic medicine; nature, including and without limitation: Health
environmental medicine including the field of Care Services primarily to assist in the activities
What Is Not Covered?
3-1
of daily living; rest homes; home companions or treatment of cancer that have not been
sitters; 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 for the sole purposes of allowing a family
member or caregiver of a Covered Person to from a pharmacy. This exclusion does not
return to work. apply to drugs dispensed to you when:
Dental Care or treatment of the teeth or their a• you are an inpatient in a Hospital,
supporting structures or gums, or dental Ambulatory Surgical Center, Skilled
procedures, including but not limited to:
Nursing Facility, Psychiatric Facility or a
extraction of teeth, restoration of teeth with or Hospice facility;
without fillings, crowns or other materials, b. you are in the outpatient department of
bridges, cleaning of teeth, dental implants, a Hospital;
dentures, periodontal or endodontic procedures, c. dispensed to your Physician for
orthodontic treatment(e.g., braces), intraoral administration to you in the Physician's
prosthetic devices, palatal expansion devices, office and prior coverage authorization
bruxism appliances, and dental x-rays. This has been obtained (if required); and
exclusion also applies to Phase II treatments(as
defined by the American Dental Association)for d• you are receiving Home Health Care
TMJ dysfunction. This exclusion does not apply according to a plan of treatment and the
to an Accidental Dental Injury and the Child Cleft Home Health Care Agency bills us for
Lip and Cleft Palate Treatment Services such drugs, Including Self-Administered
category as described in the "What Is Covered?" Prescription Drugs that are rendered in
section. connection with a nursing visit.
Drugs 3. Any non-Prescription medicines, remedies,
vaccines, biological products (except
1. Prescribed for uses other than the Food and insulin), pharmaceuticals or chemical
Drug Administration (FDA)approved label compounds, vitamins, mineral supplements,
indications. This exclusion does not apply to fluoride products, over-the-counter drugs,
any drug that has been proven safe, products, or health foods, except as
effective and accepted for the treatment of described in the Preventive Health Services
the specific medical Condition for which the category of the"What Is Covered?"section.
drug has been prescribed, as evidenced by
the results of good quality controlled clinical 4. Any drug which is indicated or used for
studies published in at least two or more sexual dysfunction (e.g., Cialis, Levitra,
peer-reviewed full length articles in Viagra, Caverject). The exception described
respected national professional medical in exclusion number one above does not
journals. This exclusion also does not apply apply to sexual dysfunction drugs excluded
to any drug prescribed for the treatment of under this paragraph.
cancer that has been approved by the FDA 6. Any Self-Administered Prescription Drug not
for at least one indication, provided the drug indicated as covered in the'What Is
is recognized for treatment of your particular Covered?"section of this Benefit Booklet.
cancer in a Standard Reference
Compendium or recommended for treatment 6. Blood or blood products used to treat
of your particular cancer in Medical hemophilia, except when provided to you
Literature. Drugs prescribed for the for:
What Is Not Covered?
2
|
|
a. emergency stabilization; arches; chronic foot strain; trimming of toenails
b. during a covered inpatient stay; or corns, or calluses.
o. when proximately related toasurgical General Exclusions ino|ude, but are not limited
procedure. to:
The exceptions to the exclusion for drugs 1' any Health Care Service received prior tm
purchased or dispensed b*aphannacy your Effective Date or after the date your
described in subparagraph number two do coverage terminates;
not apply to hemophilia drugs excluded
und�rthi�oubpar�8roph' 2' any Semioeho diagnose or treat any
Condition resulting from orinconnection
7. Drugs, which require prior coverage with your job oremployment;
authorization when prior coverage 3. any Health Care Services not within the
authorization ia not obtained.
service categories described in the'What is
8^ Specialty Drugs used ho increase height or Covenad?"section, any rider, or
bone growth (e.g.. growth hormone) except Endorsement attached hereto, unless such
for Conditions of growth hormone deficiency services are specifically required 0mbe
documented with two abnormally low covered by applicable law;
stimulation tests of less than 1Ong/m|and 4. any Health Care Services provided by a
one abnormally low growth hormone
dependent pept|deor for(�ond|�onso{ phyo|oi�norothorheo|thoonapnovidmr
gro«�h hormone deficiency associated vvith m»|��dt�youb»�|opd �rmn�rri���|
loss mf pituitary function due totrauma, 5' any Health Care Service which ionot
surgery, tumors, radiation or disease, prfor Medically Necessary oa determined byuaor
state mandated use am|n patients with Monroe County BOCC and defined inthis
AIDS. Booklet. The ordering cf a Service b*a
Continuation of growth hormone therapy will health care Provider does not|n itself make
not be covered except for Conditions; such Service Medically Necessary ora
'
aeooni�edwdhaign� Covered Service;
significant
deficiency when there ia evidence of 8' any Health Care Services rendered atno
continued responsiveness botreatment. ohoqJm|
(See'What isCovered?"section for 7. expenses for claims denied because we did
additional information.)` not receive information requested from you
Experimental mr Investigational Services, regarding whether or not you have other
except no otherwise covered under the Bone coverage and the details of such coverage;
Marrow Transplant provision uf the Transplant B. any Health Care Services bo diagnose or
Services category. treat oCondition which, directly orindirectly,
Food and Food Products prescribed ornot, resulted from orioin connection with:
except as covered inthe Enteral Formulas a0 war whether declared
subsection of the �Vhot|oC�ovenedY"menU 'section. ' '
or not;
Foot Care which ho routine, including any Health b) your participation in, mr commission of
Care This any act punishable bylaw as '
(�
exclusion includes, but|s not limited to: non' misdemeanor or felony, orwhich
aurQ|oa|treatment ofbunions; flat feet;fallen constitutes riot, or rebellion;
What|o Not Covered?
&3
C) your engaging in an illegal occupation; Arrangement. This exclusion applies to all
d) Services received at military or expenses for prenatal, intra-partal, and post-
government facilities; or partal Maternity/Obstetrical Care, and Health
e) Services received to treat a Condition Care Services rendered to the Covered Person
arising out of your service in the armed acting as a Gestational Surrogate.
forces, reserves and/or National Guard; For the definition of Gestational Surrogate and
f) Services that are not patient-specific, as Gestational Surrogacy Contract see the
determined solely by us. Definitions section of this Benefit Booklet.
9. Health Care Services rendered because Oral Surgery except as provided under the
they were ordered by a court, unless such 'What Is Covered?"section.
Services are Covered Services under this Orthomolecular Therapy including nutrients,
Benefit Booklet; and vitamins, and food supplements.
10, any Health Care Services rendered by or Oversight of a medical laboratory by a
through a medical or dental department Physician or other health care Provider.
maintained by or on behalf of an employer, "Oversight'as used in this exclusion shall,
mutual association, labor union, trust, or include, but Is not limited to,the oversight of:
similar person or group; or 1. the laboratory to assure timeliness,
11. Health Care Services that are not direct, reliability, and/or usefulness of test results;
hands-on, and patient specific, including, but 2. the calibration of laboratory machines or
not limited to the oversight of a medical testing of laboratory equipment;
laboratory to assure timeliness, reliability,
and/or usefulness of test results, or the 3. the preparation, review or updating of any
oversight of the calibration of laboratory protocol or procedure created or reviewed
machines, equipment, or laboratory by a Physician or other health care Provider
technicians. in connection with the operation of the
Genetic screening, including the evaluation of laboratory; and
genes to determine if you are a carrier of an 4. laboratory equipment or laboratory
abnormal gene that puts you at risk for a personnel for any reason.
Condition, except as provided under the Personal Comfort, Hygiene or Convenience
Preventive Health Services category of the Items and Services deemed to be not Medically
"What Is Covered?"section. Necessary and not directly related to your
Hearing Aids (external or implantable) and treatment including, but not limited to:
Services related to the fitting or provision of 1. beauty and barber services;
hearing aids, including tinnitus maskers, 2. clothing including support hose;
batteries, and cost of repair. 3. radio and television;
Immunizations except those covered under the 4. guest meals and accommodations;
Preventive Health Services category of the S. telephone charges;
"What Is Covered?"section.
6. take-home supplies;
Maternity Services rendered to a Covered
7. travel expenses (other than Medically
Person who becomes pregnant as a Gestational Necessary Ambulance Services);
Surrogate under the terms of, and in accordance 8. motel/hotel accommodations;
with, a Gestational Surrogacy Contract or
What Is Not Covered?
34
9. air conditioners,furnaces, air filters, air or conditioning programs such as athletic training,
water purification systems, water softening bodybuilding, exercise,fitness,flexibility, and
systems, humidifiers, dehumidifiers, vacuum diversion or general motivation.
cleaners mr any other similar equipment and
devices used for environmental control orto �rm�������� ����m�K��s� �mm�mmmn�. or
enhance mn environmental setting; materials, including, but not limited bmprograms
10' hot tubs, Jacuzzis, heated spas, pools, mr pr materials for pain management and
memberships to health clubs; vocational rehabilitation, except aoprovided
under the Diabetes Outpatient Self Management
11. heating pads, hot water bottles, orice packs; category mf the What|oCmvmmad?"section.
12. physical fitness equipment;
13' h�ndmai|oandgnabboro| mnd Travel or vacation expenses even �prescribed
mr ordered byaProvider.
14. Massages except oa covered in the"What/s
CoveredY"section ofthis Booklet. Volunteer Services or Services which would
Private Duty Nursing ��amwrendered a1any norrnoUy�� provid�dfro�ofuh�rgeandany
charges associated with Deductible
location. '
Coinsurance, orCopayment(if applicable)
Rehabilitative Therapies provided onan requirements which are waived bym health care
inpatient or outpatient basis, except anprovided Provider.
in the Hospital, Skilled Nursing Facility, Home Weight Control Services including any service
Health Care, and Outpatient Cardiac, to |ooe, gain, or maintain waight including
Occupational, Physical, Massage without limitation: any weightuo'''boN000
Therapies and Spinal Manipulations categories
ofth��Vhod|n<�o�onad?"aoodon' pro0n*nn| appetite suppressants; dietary
regimens; food or food supplements; exercise
Rehabilitative Therapies provided for the
programs;
n��� a�uipm�nt| whe�h�rornc*i�iop�dof
�tnzatmentp|anforaCond0on
your(�ondiUonare also excluded.
'
Reversal of Voluntary, Surgica8ly-Induced Wigs and/or cranial prosthesis.
Sterility including the reversal oftuba| Ugobono
and vasectomies.
Sexual Reassignment, onModification
Services |no|uding, but not limited to, any Health
Care Services related to such treatment, such
ao psychiatric Services.
Smoking Cessation Programs including any
service to eliminate or reduce the dependency
on, or addiction to, tobacco, including but not
limited tm nicotine withdrawal programs and
nicotine products(e.g.. gum,tosnadarma|
patches, etc.).
Sports-Related devices and services used to
affect performance primarily insports-related
activities; all expenses related bophysical
What w Not Covered?
3-5
Section 4: Medical Necessity
In order for Health Care Services to be covered 1. staying in the Hospital because
under this Booklet, such Services must meet all arrangements for discharge have not been
of the requirements to be a Covered Service, completed;
including being Medically Necessary, as defined 2. use of laboratory, x-ray, or other diagnostic
by this Benefit Booklet. testing that has no clear indication, or is not
It is important to remember that any review of expected to alter your treatment;
Medical Necessity we undertake Is solely for the 3. staying in the Hospital because supervision
purposes of determining coverage, benefits, or
payment under the terms of this Booklet and not in the home, or care in the home, is not
for the purpose of recommending or providing available or is inconvenient; or being
medical care. In conducting a review of Medical hospitalized for any Service which could
Necessity, BCBSF may review specific medical have been provided adequately in an
facts or information pertaining to you. Any such alternate setting (e.g., Hospital outpatient
review, however, is strictly for the purpose of department or at home with Home Health
determining whether a Health Care Service Care Services); or
provided or proposed meets the definition of 4. inpatient admissions to a Hospital, Skilled
Medical Necessity in this Booklet. In applying Nursing Facility, or any other facility for the
the definition of Medical Necessity in this purpose of Custodial Care, convalescent
Booklet to a specific Health Care Service, care, or any other Service primarily for the
coverage and payment guidelines then in effect convenience of the patient or his or her
may be applied by BCBSF. family members or a Provider.
All decisions that require or pertain to Note: Whether or not a Health Care Service
independent professional medical/clinical is specifically listed as an exclusion, the fact
judgement or training, or the need for medical that a Provider may prescribe, recommend,
services, are solely your responsibility and that approve, or furnish a Health Care Service
of your treating Physicians and health care does not mean that the Service is Medically
Providers. You and your Physicians are Necessary(as defined by this Benefit
responsible for deciding what medical care Booklet) or a Covered Service. Please refer
should be rendered or received and when that to the"Definitions"section for the
care should be provided. Monroe County BOCC definitions of"Medically Necessary"or
is ultimately responsible for determining whether "Medical Necessity".
expenses incurred for medical care are covered
under this Booklet. In making coverage
decisions, neither BCBSF nor Monroe County
BOCC will be deemed to participate in or
override your decisions concerning your health
or the medical decisions of your health care
Providers.
Examples of hospitalization and other Health
Care Services that are not Medically Necessary
include, but are not limited to:
Wdleal Necessity 4-1
Section 5: Understanding Your Share of Health Care
Expenses
This section explains what your share of the Benefits for the specific Covered Services which
health care expenses will be for Covered are subject to a Copayment. Listed below Is a
Services you receive. In addition to the brief description of some of the Copayment
information explained in this section, it is requirements that may apply to your plan. If the
important that you refer to your Schedule of Allowed Amount or the Provider's actual charge
Benefits to determine your share of the cost with for a Covered Service rendered is less than the
regard to Covered Services. Copayment amount, you must pay the lesser of
the Allowed Amount or the Provider's actual
Deductible Requirement charge for the Covered Service.
Individual Deductible 1. Office Services Copayment:
This amount, when applicable, must be satisfied If your plan is a Copayment plan, the
by you and each of your Covered Dependents Copayment for Covered Services rendered
each Benefit Period, before any payment will be in the office(when applicable) must be
made by the Group Health Plan. Only those satisfied by you, for each office Service
charges indicated on claims received for before any payment will be made. The
Covered Services will be credited toward the office Services Copayment applies
individual Deductible and only up to the regardless of the reason for the office visit
and applies to all Covered Services
applicable Allowed Amount. Please see your rendered in the office, with the exception of
Schedule of Benefits far more information. Durable Medical Equipment, Medical
Family Deductible Pharmacy, Prosthetics, and Orthotics.
If your plan includes a family Deductible, after Generally, if more than one Covered Service
the family Deductible has been met by your that is subject to a Copayment is rendered
family, neither you nor your Covered during the same office visit, you will be
Dependents will have any additional Deductible responsible for a single Copayment which
responsibility for the remainder of that Benefit will not exceed the highest Copayment
Period. The maximum amount that any one specified in the Schedule of Benefits for the
Covered Person in your family can contribute particular Health Care Services rendered.
toward the family Deductible, if applicable, is the 2. Inpatient Facility Copayment:
amount applied toward the individual Deductible.
Please see your Schedule of Benefits for more The inpatient facility Copayment must be
information. satisfied by you, for each inpatient
admission to a Hospital, Psychiatric Facility,
Copayment Requirements or Substance Abuse Facility, before any
Covered Services rendered by certain Providers payment will be made for any claim for
inpatient Covered Services. The inpatient
or at certain locations or settings will be subject facility Copayment applies regardless of the
to a Copayment requirement. This is the dollar reason for the admission, and applies to all
amount you have to pay when you receive these inpatient admissions to a Hospital,
Services. Please refer to your Schedule of Psychiatric Facility or Substance Abuse
Understanding Your Share of Health Care Expenses 5,_1
Facility in or outside the state of Florida. will still be responsible for the inpatient
Additionally, you will boresponsible for out- fan|bv Copayment.
of-pocket expenses for Covered Services
provided by Physicians and other health Hospital Per Admission Deductible
care professionals for inpatient admissions. The Hospital Per Admission Deductible (pA0)
Note: Inpatient facility Copaymentsmay must be satisfied bv each Covered Plan
vary depending on the facility chosen. Participant,for each Hospital admission, before
(Please see the Schedule of Benefits for any payment will be made for any claim for
more information). inpatient Health Care Services. The Hospital
3. Outpatient Facility Copaymmnt Per Admission Deductible applies regardless of
the reason for the admission, |min addition bothe
The outpatient facility Copayment must ba Deductible requirement, and applies toall
satisfied by you, for each outpatient visit toa Hospital admissions inmr outside the state of
Hospital, Ambulatory Surgical Center, Florida.
Independent Diagnostic Testing Facility,
Psychiatric Facility or Substance Abuse Emergency Room Per Visit
F�uci|ih/, before any payment will be made for Deductible
any claim for outpatient Covered Services.
The Emergency Room Per VisitDeductible
The Outpatient Facility Copaymentapplies (p��O\ |o set fodhin the Schedule ofBonofdo'
regardless of the reason for the viait and ' '
' The Emergency Room Per Visit Deductible
applies to all outpatient visits toaHospital, applies regardless of the reason for the visit, is
Psychiatric Facility or Substance Abuse
|n addition to the Deductible, and applies tm
Facility in or outside the state of Florida. emergency room services |nor outside the state
Additionally, you will be responsible for out- . of Florida. The ErnerQenoyRoom Per\�sit
of-pocketo�pengeoforC�overad �on/|�ea
��eduotib|emust bm satisfied by each <�ovemad
providodbyPhyain|�nandmth�rhaa|thn�nn
professionals.
Plan Pa�inipantfor each visit. |f the (�overod
�
Plan Participant|o admitted to the Hospital adthe
Note: Outpatient facility Co9mynnemtsmay time of the emergency room visit, the
vary depending on the facility chosen. Emergency Room Per Visit Deductible will be
(Please see the Schedule of Benefits for waived.
more information�
'' Coinsurance Requirements
4. Emergency Room Facility Copaymant'
' All applicable Deductible orCopaymentamounts
The emergency room facility Copayment must bo satisfied before any portion ofthe
applies regardless nf the reason for the visit, Allowed Amount will bm paid for Covered
imin addition to the applicable Coinsurance Services. For Services that are subject to
amount, and applies to emergency room Coinsurance, the Coinsurance percentage ofthe
facility Services in or outside the state of applicable Allowed Amount you are responsible
Florida. The emergency room facility for|o listed in the Schedule ofBenefits.
Copayment must bo satisfied by you for
each visit. If you are admitted to the Out-of-Pocket Maximums
Hospital mman inpatient at the time oYthe
emergency room visit, the emergency room Individual out-of-pocket maximum
facility Copaymant will be waived, but you Once you have reached the individual out'of-
pocksdmaximumamnountUotod |nthoGchedu|a
Understanding Your Share m Health Care Expenses 5-2
of Benefits, you will have no additional out-of- Booklet. This provision is only applicable for you
pocket responsibility for the remainder of that during the initial Benefit Period of coverage
Benefit Period and we will pay 100 percent of under this Benefit Booklet and the following
the Allowed Amount for Covered Services rules apply:
rendered during the remainder of that Benefit
Period. 1. Prior Coverage Credit for Deductible:
Family out-of-pocket maximum For the initial Benefit Period of coverage
under this Benefit Booklet only,charges
If your plan includes a family out-of-pocket credited towards your Deductible
maximum, once your family has reached the requirement under the prior policy or plan,
family out-of-pocket maximum amount listed in for Services rendered during the 90-day
the Schedule of Benefits, neither you nor your period immediately preceding the Effective
covered family members will have any additional Date of the coverage under this Benefit
out-of-pocket responsibility for the remainder of Booklet, will be credited to the Deductible
that Benefit Period and we will pay 100 percent requirement under this Booklet.
of the Allowed Amount for Covered Services
rendered during the remainder of that Benefit 2. Prior Coverage Credit for Coinsurance:
Period. The maximum amount any one Covered Charges credited by Monroe County
Person in your family can contribute toward the BOCC's prior policy or plan,towards your
family out-of-pocket maximum, if applicable, is Coinsurance Maximum, for Services
the amount applied toward the individual out-of- rendered during the 90-day period
pocket maximum. Please see your Schedule of immediately preceding the Effective Date of
Benefits for more information. coverage under this Benefit Booklet, will be
Note: The Deductible, PAD, PVD, any credited to your out-of-pocket maximum
applicable Copayments and Coinsurance under this Booklet.
amounts will accumulate toward the out-of- 3. Prior coverage credit towards the Deductible
pocket maximums. Any benefit penalty or out-of-pocket maximums will only be
reductions, non-covered charges or any charges given for Health Care Services which would
in excess of the Allowed Amount will not have been Covered Services under this
accumulate toward the out-of-pocket maximums. Booklet.
Prior Coverage Credit 4. Prior coverage credit under this Booklet only
applies at the initial enrollment of the entire
You will be given credit for the satisfaction or Group. You and/or Monroe County BOCC
partial satisfaction of any Deductible and are responsible for providing BCBSF with
Coinsurance maximums met by you under a any information necessary for BCBSF to
prior group insurance, blanket insurance, or apply this prior coverage credit.
franchise insurance or group Health
Maintenance Organization (HMO) policy or plan Benefit Maximum Carryover
maintained by Monroe County BOCC if the
coverage provided hereunder replaces such a If immediately before the Effective Date of the
policy or plan. This provision only applies if the coverage under this Benefit Booklet, you were
prior group insurance, blanket insurance, covered under a prior Monroe County BOCC
franchise insurance, HMO or plan coverage was group plan insured or administered by BCBSF,
in effect immediately preceding the Effective amounts applied to your benefit maximums
Date of the coverage provided under this Benefit
Understanding Your Share of Health Care Expenses 5,3
under the prior group plan, will be applied
toward your benefit under this Booklet,
Additional Expenses You Must Pay
|n addition to your share ofthe expenses
described above, you are also responsible for:
1. any applicable Cmpaymanta|
2. expenses incurred for non-covered
Services;
3. charges in excess of any maximum benefit
limitation listed in the Schedule ofBenefits
(e.g..the Benefit Period rnax|mummd'
''
4. charges |n excess of the Allowed Amount for
Covered Services rendered bxProviders
who have not agreed to accept the Allowed
Amount oo payment infull;
5. any benefit reductions;
6. payment of expenses for claims denied
because we did not receive information
requested from you regarding whether ornot
you have other coverage and the details cf
such coverage; and
7. charges for Health Cane Services which are
exc|uded.
Additionally, you are responsible for any
contribution amount required byMonroe County
B[JCC.
How Benefit Maximums Will Be
Credited
Only amounts actually paid for Covered
Services will be credited towards any applicable
benefit maximums. The amounts paid which are
credited towards your benefit maximums will ba
based on the Allowed Amount for the Covered
8on/icaa provided.
Understanding Your Share m Health Care Expenses
e-4
Section 6: Physicians, Hospitals and Other Provider
Options
Introduction continuing a relationship with a Family Physician
It is important for you to understand how the allows the physician to become knowledgeable
Provider you select and the setting in which you about you and your family's health history. A
receive Health Care Services affects how much Family Physician can help you determine when
you are responsible for paying under this you need to visit a specialist and also help you
Booklet. This section, along with the Schedule find one based on their knowledge of you and
of Benefits, describes the health care Provider your specific healthcare needs. Types of Family
options available to you and the payment rules Physicians are Family Practitioners, General
for Services you receive. Practitioners, Internal Medicine doctors and
Pediatricians. Additionally, care rendered by
As used throughout this section "out-of-pocket Family Physicians usually results in lower out-of-
expenses"or"out-of-pocket" refers to the pocket expenses for you. Whether you select a
amounts you are required to pay including any Family Physician or another type of Physician to
applicable Copayments,the Deductible and/or render Health Care Services, please remember
Coinsurance amounts for Covered Services. that using In-Network Providers may result in
lower out-of-pocket expenses for you. You
You are entitled to preferred provider type should always determine whether a Provider is
benefits when you receive Covered Services In-Network or Out-of-Network prior to receiving
from In-Network Providers. You are entitled to Services to determine the amount you are
traditional program type benefits at the point of responsible for paying out-of-pocket.
service when you receive Covered)Services
from Traditional Program Providers or BlueCard Location of Service
(Out-of-State)Traditional Program Providers„ in
conformity with Section 7: BlueCard (Out-of- In addition to the participation status of the
State) Program. Provider, the location or setting where you
receive Services can affect the amount you pay.
Provider Participation Status For example, the amount you are responsible for
paying out-of-pocket will vary whether you
With BlueCiptions, you may choose to receive receive Services in a Hospital, a Provider's
Services from any Provider. However, you may office, or an Ambulatory Surgical Center.
be able to lower the amount you have to pay for Please refer to your Schedule of Benefits for
Covered Services by receiving care from an In- specific information regarding your out-of-pocket
Network Provider. Although you have the option expenses for such situations. After you and
to select any Provider you choose, you are your Physician have determined the plan of
encouraged to select and develop a relationship treatment most appropriate for your care, you
with an In-Network Family Physician. There are should refer to the "What Is Covered?"section
several advantages to selecting a(Family and your Schedule of Benefits to find out if the
Physician. Family Physicians are trained to specific Health Care Services are covered and
provide a broad range of medical care and can how much you will have to pay. You should also
be a valuable resource to coordinate your consult with your Physician to determine the
overall healthcare needs. Developing and most appropriate setting based on your health
care and financial needs.
Physicians,Hospitals and Other Provider Options 8=1
To verify if a Provider is In-Network benefit plan, the Provider is considered Out-of-
for your plan you can: Network.
1. If in Florida, review your current BlueOptions
Provider Directory;
2. If in Florida, access the BlueOptions
Provider directory at BCBSF's web-site at
www.floridablue.com; and/or
3. If outside of Florida, access the on-line
BlueCard Doctor and Hospital Finder at
www.floridablue.com.; and/or
4. Call the customer service phone number in
this Booklet or on your Identification Card to
search for PPO providers.
Please remember that changes to Provider
network participation can occur at any time.
Consequently, it is your responsibility to
determine whether a specific Provider is In-
Network at the time you receive Covered
Services.
In-Network Providers
When you use In-Network Providers, your out-
of-pocket expenses for Covered Services may
be lower. Payment will be based on the Allowed
Amount and your share of the cost will be at the
In-Network benefit level listed in the Schedule of
Benefits.
Out-of-Network Providers
When you use Out-of-Network Providers your
out-of-pocket expenses for Covered Services
will be higher. We will base our payment on the
Allowed Amount at the Coinsurance percentage
listed in the Schedule of Benefits. Further, if the
Out-of-Network Provider is a Traditional
Program Provider or a BlueCard (Out-of-State)
Traditional Program Provider, our payment to
such Provider may be under the terms of that
Provider's contract. If your Schedule of Benefits
and BlueOptions Provider directory do not
include a Provider as In-Network under your
Physicians,Hospitals and Other Provider Options 6-2
In-Network Out-of-Network
What expenses • Any applicable Copayments, Deductible(s)and/or Coinsurance requirements;
are you • Expenses for Services which are not covered;
responsible for • Expenses for Services in excess of any benefit maximum limitations;
paying? • Expenses for claims denied because we did not receive information
requested from you regarding whether or not you have other coverage and
the details of such coverage; and
• Expenses for Services which are excluded.
Who is • The Provider will file the claim for You are responsible for filing the
responsible for you and payment will be made claim and payment will be made
filing your directly to the Provider. directly to the Covered Plan
claims? Participant. If you receive Services
from a Provider who participates in
our Traditional Program or is a
BlueCard (Out-of-State)Traditional
Program Provider, the Provider will
file the claim for you. In those
instances payment will be made
directly to the Provider.
Can you be billed • NO. You are protected from • YES. You are responsible for paying
the difference being billed for the difference in the difference between what we pay
between what the the Allowed Amount and the and the Provider's charge. However,
Provider Is paid Provider's charge when you use if you receive Services from a
and the Provider's In-Network Providers. The Provider who participates in our
charge? Provider will accept the Allowed Traditional Program, the Provider will
Amount as payment in full for accept our Allowed Amount as
Covered Services except as payment in full for Covered Services
otherwise permitted under the since such Traditional Program
terms of the Provider's contract Providers have agreed not to bill you
and this Booklet, for the difference, Further, under the
BlueCard (Out-of-State) Program,
when you receive Covered Services
from a BlueCard (Out-of-State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In-Network or Out-of-Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians,Hospitals and Other Provider Options B
�
"."ys�wwwmm* admits toby contacting the office.
This will prqvdeyou w�hinfornlob U
information
VVhenyou reoa�e Covered Gen�naefnonna he|pyou - -determine apo�iongf what your ou� ��
phyoio|mnyouvviU --be pocket costs beintheoventyouan*
��opoyment and/or the DeducUb|eand the hospitalized.
�
applicable Coinsurance. Several factors will
determine your out-of-pmokot expenses including Refer toyour Schedule uf Benefits todetermine
your Schedule mf Benefits,whether the the applicable out-of'pocket expenses you are
Physician |s In-Network orOut'of-Neb«ork,the responsible for paying for Hospital Services.
location mf service,the type o{Service mandonnd
and the Physician's specialty. ' Specialty Pharmacy
Remember that the location or setting where a Certain medications, such oo injectable, oral,
Service |a rendered can affect the amount you inhaled and infused therapies used totreat
are responsible for paying out-of'poobet. After complex medical Conditions are typically more
you and your Physician have determined the difficult to maintain, administer and monitor
plan mf treatment most appropriate for your care, when compared to traditional Drugs. Specialty
you should refer bo the Schedule of Benefits and Drugs may require frequent dosage
consult with your Physician*n determine the adjustments, special storage and handling and
most appropriate setting based on your health may not bo readily available sd local pharmacies
care and financial needs. or routinely stocked by Physicians'offices,
Refer tm your Schedule pfBenefits to determine mostly due to the high cost and complex
the applicable Copoyments. Coinaumanue handling they require.
percentage and/or Deductible amount you are Using the Specialty Pharmacy to provide these
responsible for paying for Physician Services. Specialty Drugs should lower the amount you
Hospitals have to pay for these medications, while helping
bo preserve your benefits.
Each time you receive inpatient oroutpatient
Other Providers
Covered Services ada Hospital, in addition tm
any out'of-pookat expenses related tuPhysician With B|ua{3pbono you have access toother
Services, you will bm responsible for out �`�ip�a Providers inaddibqntm the ones previously
pocket expenses related ho Hospital Sa"
', ' described in this section. Other Providers
In-Network Hospitals have been divided into two include facilities that provide alternative
groups that are referred toao^opt|ons'onthe outpatient settings or other persons and entities
Schedule ofBenefits. The amount you are that specialize ina spec|fio8amice(m). While
responsible for paying out-of'pochedisdifferent these Providers may be recognized for payment,
for each of these options. Remember that there they may not be included aoIn-Network
are also different out-of-pookot expenses for Providers for your plan. Additionally, all pfthe
Out-of-Network Hospitals. Services that are within the scope of certain
Since not all Physicians admit patients tmevery Providers' licenses may not bmCovered
Hospital, it|a important when choosing a Services under this Booklet. Please refer tothe
Physician that you determine the Hospitals 'What|oC:ovenad?°and 'What /m Not Covored?"
where your Physician has admitting privileges. sections ofthis BooWetand your Schedule of
Youoenf|ndoutwha1Hoopita|myourphyoioia' Benefits bo determine your out'of-ponkot
Physicians,Hospitals and Other Provider Options
6-4
expenses for Covered Services rendered by 4) is a BlueCard (Out-of-State) PPO Program
these Providers. Provider; 5) is a BlueCard (Out-of-State)
You may be able to receive certain outpatient Traditional Program Provider; 6) is a licensed
Services at a location other than a Hospital. The Hospital, Physician, or dentist and the benefits
amount you are responsible for paying for which have been assigned are for care provided
Services rendered at some alternative facilities pursuant to section 395.1041, Florida Statutes;
is generally less than if you had received those or 7) is an Ambulance Provider that provides
same Services at a Hospital. transportation for Services from the location
where an "emergency medical condition",
Remember that the location of service can defined in section 395.002(8) Florida Statutes,
impact the amount you are responsible for first occurred to a Hospital, and the benefits
paying out-of-pocket. After you and your which have been assigned are for transportation
Physician have determined the plan of treatment to care provided pursuant to section 395.1041,
most appropriate for your care, you should refer Florida Statutes. A written attestation of the
to the Schedule of Benefits and consult with assignment of benefits may be required.
your Physician to determine the most
appropriate setting based on your health care
and financial needs. When Services are
rendered at an outpatient facility other than a
Hospital there may be an out-of-pocket expense
for the facility Provider as well as an out-of-
pocket expense for other types of Providers.
Assignment of Benefits to Providers
Except as set forth in the last paragraph of this
section, any of the following assignments, or
attempted assignments, by you to any Provider
will not be honored:
• an assignment of the benefits due to you for
Covered Services under this Benefit
Booklet;
• an assignment of your right to receive
payments for Covered Services under this
Benefit Booklet;or
• an assignment of a claim for damage
resulting from a breach, or an alleged
breach of the terms of this Benefit Booklet.
We specifically reserve the right to honor an
assignment of benefits or payment by you to a
Provider who: 1) is In-Network under your plan
of coverage; 2) is a NetworkBlue Provider even
if that Provider is not in the panel for your plan of
coverage; 3) is a Traditional Program Provider;
Physicians,Hospitals and Other Provider Options 0-5
Section 7: B1ueCardo (Out-of-State) Program
Out-of-Area Services • The negotiated price that the Host Blue
We have a variety of relationships with other makes available to us.
Blue Cross and/or Blue Shield Licensees Often,this"'negotiated price"will be a simple
referred to generally as"Inter-Plan Programs". discount that reflects an actual price that the Host
Whenever you obtain Health Care Services Blue pays to your health care Provider.
outside of our service area, the claims for these Sometimes, it is an estimated price that takes into
Services may be processed through one of account special arrangements with your health
these Inter-Plan Programs, which 'Include the care Provider or Provider group that may include
BlueCard Program and may include negotiated types of settlements, incentive payments, and/or
National Account arrangements available other credits or charges. Occasionally, it may be
between us and other Blue Cross and Blue an average price, based on a discount that
Shield Licensees, results in expected average savings for similar
Typically, when accessing care outside our types of health care Providers after taking into
service area, you will obtain care from health account the same types of transactions as with
care Providers that have a contractual an estimated price.
agreement(i.e., are"participating providers") Estimated pricing and average pricing, going
with the local Blue Cross and/or Blue Shield forward, also take into account adjustments to
Licensee in that other geographic area ("Host correct for over-or underestimation of
Blue"). In some instances, you may obtain care modifications of past pricing for the types of
from non-participating health care Providers. transaction modifications noted above. However,
Our payment practices in both instances are such adjustments will not affect the price we use
described below, for your claim because they will not be applied
BlueCard Program retroactively to claims already paid.
Laws in a small number of states may require the
Under the BlueCard Program, when you Host Blue to add a surcharge to your calculation.
access Covered Services within the geographic If any state laws mandate other liability
area served by a Host Blue, we will remain calculation methods, including a surcharge, we
responsible for fulfilling our contractual would then calculate your liability for any Covered
obligations. However, the Host Blue is Services according to applicable law.
responsible for contracting with and generally
handling all interactions with its participating Out-of-Network Providers Outside Our
health care Providers. Service Area
Whenever you access Covered Services Your Liability Calculation
outside our service area and the claim is
When Covered Services are provided outside of
(processed through the BlueCard Program, the
amount you pay for Covered Services is our service area by non-participating health care
calculated based on the lower of: Providers, the payment will be based on the
Allowed Amount as defined in the Benefit
• The billed covered charges for your Booklet.
Covered Services; or
BlueCard(out-of-State)Program 7 1
Section 8: Blueprint for Health Programs
Introduction Psychiatric Facility, Substance Abuse Facility or
BCBSF has established (and from time to time Skilled Nursing Facility(as applicable) if we
establishes)various customer-focused health have been notified of your admission. For an
education and information programs as well as admission outside of Florida, you or the
benefit utilization management and utilization Hospital, Psychiatric Facility, Substance Abuse
review programs. Under the terms of the ASO Facility or Skilled Nursing Facility(as applicable)
Agreement between BCBSF and Monroe should notify us of the admission. Making sure
County BOCC, BCBSF has agreed to make that we are notified of your admission will enable
these programs available to you. These us to provide you information about the Blueprint
programs, collectively called the Blueprint for for Health Programs available to you. You or
Health Programs, are designed to 1) provide you the Hospital, Psychiatric Facility, Substance
with information that will help you make more Abuse Facility or Skilled Nursing Facility(as
unformed decisions about your health, 2) help applicable) may notify us of your admission by
facilitate the management and review of calling the toll free customer service number on
coverage and benefits provided under this your ID card.
Booklet and 3) present opportunities, as
explained below, to mutually agree upon put-of-Network
alternative benefits or payment alternatives for
cost-effective medically appropriate Health Care For admissions to an Out-of-Network Hospital,
Services. Some BluePrint For Health Psychiatric Facility, Substance Abuse Facility or
Programs may not be avallable outside the Skilled Nursing Facility, you or the Hospital,
state of Florida. Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility should notify BCBSF of
Admission Notification the admission. Notifying BCBSF of your
admission will enable BCBSF to provide you
The admission notification requirements vary information about the Blueprint far Health
depending an whether you are admitted to a Programs available to you. You or the Hospital
Hospital, Psychiatric Facility, Substance Abuse may notify IBCBSF of your admission by calling
Facility or Skilled Nursing Facility which is In- the toll-free customer service number on your ID
Network or Glut-of-Network. card.
In-Network Inpatient Facility Program
Under the admission notification requirement, Under the inpatient facility program, we may
we must be notified of all inpatient admissions review Hospital stays, Hospice, Inpatient
(i.e., elective, planned, urgent or emergency)to Rehabilitation, LTAC and Skilled Nursing Facility
In-Network Hospitals, Psychiatric Facilities, (SNF) Services, and other Health Care Services
Substance Abuse Facilities or Skilled Nursing rendered during the course of an inpatient stay
Facilities. While it is the sole responsibility of or treatment program. We may conduct this
the In-Network Provider located in Florida to review while you are inpatient, after your
comply with our admission notification discharge, or as part of a review of an episode
requirements, you should ask the Hospital, of care when you are transferred from one level
Blueprint for Health Programs
of inpatient care to another for ongoing required under the terms of their agreement
treatment. The review is conducted solely to with us; or
determine whether we should provide coverage 2. we perform a focused review under the
and/or payment for a particular admission or focused utilization management program
Health Care Services rendered during that and we determine that a Health Care
admission. Using our established criteria then in Service Is not Medically Necessary in
effect, a concurrent review of the inpatient stay accordance with our Medical Necessity
may occur at regular intervals, including in criteria or inconsistent with our benefit
advance of a transfer from one inpatient facility guidelines then in effect unless the following
to another. We will provide notification to your exception applies.
Physician when inpatient coverage criteria are
no longer met. In administering the inpatient Exception for Certain NetworkBlue Physicians
facility program, we may review specific medical Certain NetworkBlue Physicians licensed as
facts or information and assess, among other Doctors of Medicine (M.D.)or Doctors of
things,the appropriateness of the Services being rendered, health care setting and/or the Osteopathy(D.O.)only may bill you for Services
determined to be not Medically Necessary by
level of care of an inpatient admission or other BCBSF under this focused utilization
health care treatment program. Any such management program if, before you receive the
reviews by us, and any reviews or assessments Service:
of specific medical facts or information which we
conduct, are solely for purposes of making a. they give you a written estimate of your
coverage or payment decisions under this financial obligation for the Service;
Benefit Booklet and not for the purpose of b. they specifically identify the proposed
recommending or providing medical care. Service that BCBSF has determined not to
Provider Focused Utilization be Medically Necessary; and
Management Program c. you agree to assume financial responsibility
Certain NetworkBlue Providers have agreed to for such Service.
participate in our focused utilization Prior Coverage Authorization/Pre-
management program. This pre-service review Service Notification Programs
program is intended to promote the efficient
delivery of medically appropriate Health Care It is important for you to understand our prior
Services by NetworkBlue Providers. Under this coverage authorization programs and how the
program we may perform focused prospective Provider you select and the type of Service you
reviews of all or specific Health Care Services receive affects these requirements and
proposed for you. In order to perform the ultimately how much you are responsible for
review, we may require the Provider to submit to paying under this Benefit Booklet.
us specific medical information relating to Health You or your Provider will be required to obtain
Care Services proposed for you. These prior coverage authorization from us for:
NetworkBlue Providers have agreed not to bill,
or collect, any payment whatsoever from you or 1. advanced diagnostic Imaging Services,
us, or any other person or entity, with respect to such as CT scans, MRIs, MRA and nuclear
a specific Health Care Service if: imaging;
1. they fail to submit the Health Care Service
for a focused prospective review when
Blueprint for Health Programs 8-2
2. Autism Spectrum Disorder; Mental customer service phone number on the back
Health; and Substance Dependency of your ID Card.
Services; and
2. In the case of Autism Spectrum Disorder,
3. other Health Care Services that are or may Mental Health,and Substance
become subject to a prior coverage Dependency Services under a prior
authorization program or a pre-service coverage authorization or pre-service
notification program as defined and notification program, it is your sole
administered by us. responsibility to comply with our prior
Prior coverage authorization requirements vary, coverage authorization or pre-service
depending on whether Services are rendered by notification requirements when rendered or
an In-Network Provider or an Out-of-Network referred by an Out-of-Network Provider,
Provider, as described below: before the Services are provided. Failure
to obtain prior coverage authorization
In-Network Providers will result In denial of coverage for such
It is the In-Network Provider's sole responsibility Services.
to comply with our prior coverage authorization 3. In the case of other Health Care Services
requirements, and therefore you will not be under a prior coverage authorization or pre-
responsible for any benefit reductions if prior service notification program, it is your sole
coverage authorization is not obtained before responsibility to comply with our prior
Medically Necessary Services are rendered. coverage authorization or pre-service
Once we have received the necessary medical notification requirements when rendered or
documentation from the Provider, we will review referred by an Out-of-Network Provider,
the information and make a prior coverage before the Services are provided. Failure
authorization decision, based on our established to obtain prior coverage authorization or
criteria then in effect. The Provider will be provide pre-service notification may
notified of the prior coverage authorization result In denial of the claim or application
decision.
of a financial penalty assessed at the
Out-of-Network Providers time the claim Is presented for payment
1. In the case of advanced diagnostic to us. The penalty applied will be the lesser
imaging Services such as CT scans, MRIs, of$500 or 20%of the total Allowed Amount
MRA and nuclear imaging, it is your sole of the claim. The decision to apply a penalty
responsibility to comply with our prior or deny the claim will be made uniformly and
coverage authorization requirements when will be identified in the notice describing the
rendered or referred by an Out-of-Network prior coverage authorization and pre-service
Provider before the advanced diagnostic notification programs.
imaging Services are provided. Your Once the necessary medical documentation has
failure to obtain prior coverage been received from you and/or the Out-of-
authorization will result In denial of Network Provider, BCBSF or a designated
coverage for such Services. vendor, will review the information and make a
For additional details on how to obtain prior prior coverage authorization decision, based on
coverage authorization for advanced our established criteria then in effect. You will
diagnostic imaging Services, please call the be notified of the prior coverage authorization
decision.
Blueprint for Heafth Programs
8.3
BCBSF will provide you information for any Out- made available on a basis when
of-Network Health Care Service subject to a you meet BCBSPs case management criteria
prior coverage authorization mnpre-service then in effect. Such alternative benefits mr
notification program, including how you can payments, if any, will be made available in
obtain prior coverage authorization and/or accordance with a treatment plan with which
provide the pre-service notification for such you, or your representative, and your Physician
Service not already listed here. This information agree toinwriting. |n addition, Monroe County
will bo provided to you upon enrollment, orot BOCC will be required to specifically agree tm
least 30 days prior to such Out-of-Nebwmrk such treatment plan and the alternative benefits
Services becoming subject tua prior coverage or payment.
authorization orpns'eervioa notification program.
The fact that certain Health Care Services under
See the"Claims Processing" section for the personal case management program have
information on what you can doif prior coverage been provided mr payment has been made |nno
authorization is denied. way obligates BCBGF. Monroe CountyBOCC.
Note: Prior coverage authorization |onot or the Group Health Plan tm continue toprovide
required when Covered Services are provided o'pay for the same nr similar Services. Nothing
for the treatment of om Emergency Medical contained |n this section shall be deemed o
Condition. waiver of Monroe County BC]CC'o right bo
Member Focused Programs enforce this Booklet in strict accordance with its
terms. The terms qfthis Booklet will continue to
The Blueprint for Health Programs may include apply, except as specifically modified inwriting
voluntary programs for certain members. These in accordance with the personal case
programs may address health promotion, management program rules then ineffect.
prevention and early detection of disease, Health Information, Promotion, Prevention
chronic illness management programs, case and Illness Management Programs
management programs and other member
fo�ume� pnogname' These B|uap�ntfor Health Programs may
include health Information that supports health
Personal Case Management Program care education and choices for healthcare
issues. These programs focus on keeping you
The personal case management program well, help bz identity early preventive measures
focuses on members who suffer from a of treatment and help covered individuals with
catastrophic illness orinjury. |n the event you chronic problems to enjoy lives that are an
have a catastrophic or chronic Condition, wm productive and healthy aopossible. These
may, |nBCBSFa sole discretion, assign a programs may include prenatal educational
Personal Case Manager to you tohelp programs and illness management programs for
coordinate coverage, benefits, mr payment for Conditions such ao diabetes, cancer and heart
Health Care Services you receive. Your d|aoaaa' These programs are voluntary and are
Participation in this Drogram is completelydesigned to enhance your abi|bvtomake
volunta . informed choices and decisions for your unique
health care needs. You may call the toll free
Under the personal case management program, customer service number on your |D card for
you may be offered alternative benefits or more information. Your artiCiDation in this
payment for cost-effective Health Care Services. Pro-gram is completely voluntary.
These alternative benefits or payments may be �----------
Blueprint for Health Programs
8-4
IMPORTANT INFORMATION RELATING TO
BCBSFrS BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain tm
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 beprovided. yNqnnom
County BOCC is ultimately responsible for
determining whether expenses, which have
been or will bo incurred for medical care are, or
will be, covered under this Booklet. In fulfilling
this responsibility, neither BC:B8F nor Monroe
County BC3CCwill be deemed to participate in or
override the medical decisions of your health
care Provider.
P|aama note that the Hospital admission
notification requirement and any Blueprint For
Health Program may be discontinued or
modified ot any time without notice to you or
your consent.
Blueprint for mmm`Programs
8-6
Section 9: Eligibility for Coverage
Each employee or other individual who is eligible the 6081 day of continuous service or
to participate in the Monroe County Group Waiting Period.
Health Plan, and who meets and continues to
meet the eligibility requirements described in this Monroe County BOCCs coverage eligibility
Booklet, shall be entitled to apply for coverage classifications may be expanded to include:
under this Booklet. These eligibility 1. retired employees;
requirements are binding upon you and/or your 2. Constitutional Officers or their Employees;
eligible family members. No changes in the
eligibility requirements will be permitted except 3. additional job classifications;
as permitted by Monroe County BOCC. 4. employees of affiliated or subsidiary
Acceptable documentation may be required as companies of Monroe County BOCC; and
proof that an individual meets and continues to
meet the eligibility requirements such as a court 5. other individuals as determined by Monroe
order naming the Eligible Employee as the legal County BOCC.
guardian or appropriate adoption documentation Monroe County BOCC shall have sole discretion
described ini the "Enrollment and Effective Date concerning the expansion of eligibility
of Coverage"section. classifications.
Eligibility Requirements for Covered Eligibility Requirements for
Plan Participants Dependent(s)
In order to be eligible to enroll as a Covered An individual who meets the eligibility criteria
Plan Participant, an individual must be an specified below is an Eligible Dependent and is
Eligible Employee or Eligible Retiree. An eligible to apply for coverage under this Booklet:
Eligible Employee must meet each of the
following requirements: 1. The Covered Plan Participant's spouse
1. The employee must be a bona fide
under a legally valid existing marriage under
Federal Law.
employee of a Monroe County Employer,
participating in the Monroe County Group 2. The Covered Plan Participant's natural,
Health Plan; newborn, adopted, Foster, or step children)
2. The employee must be actively working 25 (or a child for whom the Covered Plan
hours or more per week on a regular basis; Participant has been court-appointed as
legal guardian or legal custodian)who has
3. The employee must have completed the not reached the end of the Calendar Year in
applicable Waiting Period of 60 days of which hie or she reaches age 26(or in the
continuous service; and case of a Foster Child, is no longer eligible
4. The employee must meet any additional under the Foster Child Program), regardless
eligibility requirement(s)required by Monroe of the dependent child's student or marital
County BOCC. status,financial dependency on the Covered
Note: Employees and qualified Dependents are Plan Participant,whether the dependent
eligible for coverage on the day following child resides with the Covered Plan
Participant, or whether the dependent child
Eligibility For Coverage 9-1
is eligible for or enrolled in any other group Children
health plan.
|n the case of a handicapped dependentchUd.
3. The newborn child ofa Covered Dependent such child ie eligible to continue. nxQemoa
child who has not reached the end ofthe Covered Dependent, beyond the age of8G, if
Calendar Year in which heor she becomes the child is:
26. Coverage for such newborn child will
automa1io�Uytermin�ta1�mon�ho�fharthm 1' cdhemNseeligible for coverage under the
Group Health P|an'
b|dhmf the navvbornchild.
'
Note: |fa Covered Dependent child who has 2' incapable of self-sustaining employment by
reached the end of the Calendar Year inwhich reason of mental retardation orphysical
and
heor she beoonnoa2G obtains a dependent of handicap;
their own (e.Q.. through birth uradoption) such 3' chiefly dependent upon the Covered Plan
newborn child will not ba eligible for this Participant for support and maintenance
coverage and the Covered Dependent child will provided that the symptoms or causes ofthe
also lose his or her eligibility for this coverage. It child's handicap existed prior to the child's
is the Covered Plan Participant's sole 86mbidhdey.
responsibility bo establish that a child meets the This e|igibUbvshall terminate on the last day of
appUoeb|enaquiromnontafor eUg|bi|ib� the noonthin'which the dependent child no
This eligibility shall terminate on the last day of longer meets the requirements for extended
the Calendar Year in which the dependent child eligibility aoa handicapped child.
reaches age QG. Exception for Students on Medical Leave of
Extension of Eligibility for Dependent Absence from School
Children
ACo*ered Dependent child who |s a full-time ur
A Covered Dependent child may continue part-time student mtan accredited post-
coverage beyondthe end of the Calendar Year secondary institution, who takes ophysician
in which heor she reaches age 2G. provided he certified medically necessary leave ofabsence
or she is: from school, will still be considered a student for
eligibility purposes under this Booklet for the
1. unmarried and does not have adependent; earlier of12 months from the first day ofthe
2. a Florida resident ora full-time orpart-time leave of absence qr the date the Covered
student; Dependent would otherwise no longer boeligible
8' not enrolled in any other health coverage for coverage under this Booklet.
policy or group health plan; and
4. not entitled bz benefits under Title XVI|| of
the Social Security Act unless the child ioa
handicapped dependent child.
This eligibility shall terminate on the last day of
the Calendar Year in which the dependent child
reaches age 3O.
Section 10: Enrollment and Effective Date of Coverage
Eligible Employees, Eligible Retirees and Employee/Retiree and the employee's spouse
Eligible Dependents may enroll for coverage under a legally valid existing marriage under
according to the provisions below. Federal Law or Domestic Partner.
Any Eligible Employee, Eligible Retiree or Employee/Child(ren)Coverage-This type of
Eligible Dependent who is not properly enrolled coverage provides coverage for the
will not be covered under this Benefit Booklet. Employee/Retiree and the covered children)
Neither BCBSF nor Monroe County BOCC will only,
have any obligation whatsoever to any individual
who is not properly enrolled. Employee/Family Coverage-This type of
coverage provides coverage for the
Any Employee, Eligible Retiree, or Eligible Employee/Retiree and the Covered Dependents.
Dependent who is eligible for coverage under
this Booklet may apply for coverage according to There may be additional contribution amounts
the provisions set forth below. for each Covered Dependent based on the
coverage selected by Monroe County BOCC.
Enrollment Forms/Electing Coverage Enrollment Periods
To apply for coverage, you as the Eligible The enrollment periods for applying for coverage
Employee or Eligible Retiree must:
are as follows:
1. complete and submit, through Monroe Initial Enrollment Period is the period of time
County BOCC Benefits Office, the during which an Eligible Employee or Eligible
Enrollment Form; Dependent is first eligible to enroll. It starts on
2. provide any additional information needed to the Eligible Employee's or Eligible, Dependent's
determine eligibility, at the request of initial date of eligibility and ends no less than 30
BCBSF or Monroe County BOCC Benefits days later.
Office; Annual Open Enrollment Period is the period
3. pay any required contribution; and of time during which each Eligible Employee or
4. complete and submit,through Monroe Eligible Retiree is given an opportunity to select
County BOCC Benefits Office, an coverage from among the alternatives included
Enrollment Form to add Eligible in Monroe County BOCC's health benefit
Dependents. program. The period is established by Monroe
County BOCC, occurs annually, and will take
When making application for coverage, you place when specified by Monroe County BOCC.
must elect one of the types of coverage
available under Monroe County BOCC's Special Enrollment Period is the 30-day period
g types may include: of time unless otherwise noted immediately
program. Such ( }
following a special circumstance during which an
Employee Only Coverage-This type of Eligible Employee or Eligible Dependent may
coverage provides coverage for the apply for coverage. Special circumstances are
Employee/Retiree only. described in the Special Enrollment Period
Employee/Spouse Coverage-This type of subsection.
coverage provides coverage for the
Enrollment and Effective Date of coverage 10•1
Employee
Enrollment Enrollment event, during the Special Enrollment
Period.
An Eligible Employee who falls hoenroll during
the Initial EnroUnnontPahodv�Uncdbmnov�ned Note: For a(�o«e'ed Dependent child nvhohas
and may only enroll under this Benefit Booklet reached the end of the Calendar Year inwhich
during the next Annual Open Enrollment Period hao'she becomes 26 and the Covered
established by Monroe County BOCC. orinthe Dependent child obtains a dependent oftheir
case ofa Special Enrollment event, during the own (e'Q'. through birth orodopt|mn). such
Special Enrollment Period. The Effective Date newborn child will not bo eligible for this
will be the date specified by Monroe County coverage and cannot enroll. Further, such
BOCC. Covered Dependent child will also lose his or
her eligibility for this coverage.
Dependent Enrollment
Adopted NewbmmmChYld—TpannoUan
An individual may be added upon becoming an adopted newborn child, the Covered Plan
Eligible Dependent ofa Covered Plan Participant must submit an Enrollment Form
Participant. Below are special rules for certain through Monroe County BOCC Benefits Office to
Eligible Dependents. BCBSF during the 3O'day period immediately
following the date ofbirth. The Effective Date of
Newborn ChiYd—TuemroUanmwbornnh||dvvhu coverage for on adopted newborn child, eligible
ieon Eligible Dependent,the Covered Plan for coverage, will be the moment ofbirth,
Participant must submit an Enrollment Form to provided that a written agreement tu adopt such
BCBSF through Monroe County BOCC Benefits child has been entered into by the Covered Plan
Office during the 3O-day period immediately Participant prior h»the birth of such child,
following the date ofbirth, The Effective Date of whether or not such an agreement|a
coverage for a newborn child will bm the date of enforceable. The Covered Plan Participant may
birth
. be required to provide any information and/or
|f timely notice |m given, noadditional documents that are deemed necessary inorder
contribution will be charged for coverage mythe to administer this provision.
newborn child for not less than 3O days after the |f timely notice io given, noadditional
birth of the child. |f timely notice ia not received, contribution will bo charged for coverage ofthe
the applicable contribution will be charged from adopted newborn child for not less than 3Ddays
the date ofbirth. The applicable contribution for after the birth nf the child. |f timely notice ionot
the child will be charged after the initial 3O-day received, the applicable contribution will be
period |n either case. Coverage will not bm charged from the date ofbirth. The applicable
denied for a newborn child if the Covered Plan contribution for the child will bo charged after the
Participant provides notice to Monroe County initial 3O-day period in either case. Coverage
BC3CC Benefits Office and an Enrollment Form will not be denied for an adopted newborn child
io received within the G0'day period of the birth if the Covered Plan Participant provides notice
of the child and any applicable contribution |o to Monroe County BOCC Benefits Office and an
paid back to the date ofbirth. Enrollment Form is received within the GO-day
|f the newborn |m not enrolled within sixty days of period of the birth o{the adopted newborn child
the date mf birth, the newborn child will not bo and any applicable contribution in paid back to
covered, and may only be enrolled under this the date ofbirth.
Benefit Booklet during an Annual Open |f the adopted newborn child io not enrolled
Enrollment Period, orinthe case ofaSpecial within sixty days of the date of birth,the adopted
Enrollment and Effective Date mCoverage
10-2
newborn child will not be covered, and may only must be submitted toBCBGFthrough Monroe
ba enrolled under this Benefit Booklet during an County BOCC Benefits Office. |timthe
Annual Open Enrollment Period, orinthe case responsibility ofthe Covered Plan Participant to
of Special Enrollment event, during the Special notify BCBSF through Monroe County BOCC
Enrollment Period. Benefits Office if the adoption does not take
If the adopted newborn child is not ultimately place. Upon receipt of this notification, vw*will
placed in the residence of the Covered Plan terminate the coverage of the child asmfthe
Participant,there shall bono coverage for the Effective Date of the adopted child upon receipt
adopted newborn child. |tis your responsibility of the written notice.
aa the Covered Plan Participant hm notify Monroe If the Covered Plan Participants status eaa
C:ountyBOCC Benefits Office within ten foster parent ioterminated, coverage will end for
calendar days of the date that placement was to any Foster Child. |tio the responsibility ofthe
occur if the adopted newborn child io not placed Covered Plan Participant tonotifv B(�BSF
|n your residence. through K8onroe<�oumtyB����(� ~Benefits Office
Adopted/Foster Children_To enroll an that the Foster Child isno longer|n the Covered
adopted or Foster Child, the Covered Plan Plan Participant's care. Upon receipt ofthis
Participant must submit an Enrollment Form notification, coverage for the child will be
during the 3O'doy period immediately following terminated on the date the Covered Plan
the date of placement. The Effective Date for an Participant's status aoa foster parent
adopted or Foster child (other than anadopted terminated.
newborn child)will be the date such adopted or Marital SKatus-TheCovemad Plan Participant
Foster child |o placed |n the residence ofthe may apply for coverage ofan Eligible Dependent
Covered Plan Participant in compliance with due toa legally valid existing marriage under
applicable law. The Covered Plan Participant Federal Law. To apply for coverage, the
may be required to provide any information Covered Plan Participant must complete the
and/or documents deemed necessary|n order bo Enrollment Form through Monroe County BO[|C
properly administer this section. Benefits Office and forward |ttmBCBSP. The
|n the event Monroe County BOCCBenefits Covered Plan Participant must make application
Office is not notified within 3O days of the date mf for enrollment within Q0 days of the marriage.
placement, the child will ba added 000f the date The Effective Date of coverage for anEligible
of placement oo long mo Covered Plan Dependent who ia enrolled aaa result of
Participant provides notice toMonroe County marriage ia the date pf the marriage.
BOCC Benefits Office, and we receive the Court Orden-TheCovmrodP|anPadioipant
Enrollment Form within 8D days ofthe may apply for coverage for anEligible
p|enonnant. |f the adopted or Foster Child imnot Dependent outside of the Initial Enrollment
enrolled within sixty days ofthe date of Period and Annual Open Enrollment Period |fa
placement, the adopted or Foster Child will not court has ordered coverage tobe provided for a
be covered, and may only be enrolled under this minor child under their group coverage. To
Benefit Booklet during an Annual Open apply for coverage, the Covered Plan Participant
Enrollment Period, orin the case ofa Special must complete on Enrollment Form through
Enrollment event, during the Special Enrollment Monroe County BOCC Benefits Office and
Period. For all children covered as adopted forward it to BCBSF. The Covered Plan
children, if the final decree mf adoption ionot Participant must make application for enrollment
Issued, coverage shall not be continued for the within 80 days of the court order. The Effective
proposed adopted Child. Proof mf final adoption Date of coverage for en Eligible Dependent who
Enrollment and Effwm*o Date mCoverage 10-3
1
i
is enrolled as a result of a court order is the date 1. If you lose your coverage under another
required by the court. group health benefit plan (as an employee
or dependent), or coverage under other
Annual Open Enrollment Period health insurance (except in the case of loss
Eligible Employees and/or Eligible Dependents of coverage under a Children's Health
who did not apply for coverage during the Initial Insurance Program (CHIP) or Medicaid, see
#3 below), or COBRA continuation
Enrollment Period or a Special Enrollment coverage that you were covered under at
Period may apply for coverage during an Annual
Open Enrollment Period. The Eligible Employee the time of initial enrollment provided that:
may enroll by completing the Enrollment Form a) when offered coverage under this plan
during the Annual Open Enrollment Period. at the time of initial eligibility, you stated,
The effective date of coverage for an Eligible in writing, that coverage under a group
Employee and any Eligible Dependent(s)will be health plan or health insurance
the date established by Monroe County BOCC coverage was the reason for declining
Benefits Office.
enrollment; and
Eligible Employees who do not enroll or change b) you lost your other coverage under a
their coverage selection during the Annual Open group health benefit plan or health
Enrollment Period, must wait until the next insurance coverage (except in the case
Annual Open Enrollment Period, unless the of loss of coverage under a CHIP or
Eligible Employee or the Eligible Dependent is Medicaid, see#3 below) as a result of
enrolled due to a special circumstance as termination of employment, reduction in
outlined in the Special Enrollment Period the number of hours you work, reaching
or exceeding the maximum lifetime of all
subsection of this section. benefits under other health coverage,
Special Enrollment Period the employer ceased offering group
health coverage, death of your spouse,
An Eligible Employee and/or the Employee's divorce, legal separation or employer
Eligible Dependent(s) may apply for coverage contributions toward such coverage was
outside of the Initial Enrollment Period and terminated; and
Annual Enrollment Period as a result of a special c) you submit the applicable Enrollment
enrollment event. To apply for coverage, the Form to the Group within 30 days of the
Eligible Employee and/or the Employee's date your coverage was terminated
Eligible Dependent(s) must complete the
applicable Enrollment Form and forward it to Note: Loss of coverage for failure to pay
Monroe County BOCC Benefits Office within the Your required contribution/premium on a
timely basis or for cause (such as making a
time periods noted below for each special fraudulent claim or an intentional
enrollment event. misrepresentation of a material fact in
An Eligible Employee and/or the Employee's connection with the prior health coverage) is
Eligible Dependent(s) may apply for coverage if not a qualifying event for special enrollment.
one of the following special enrollment events or
occurs and the applicable Enrollment Farm is
submitted to Monroe County BOCC Benefits 2. If when offered coverage under this plan at
Office within the indicated time periods: the time of initial eligibility, you stated, in
writing, that coverage under a group health
plan or health insurance coverage was the
Enrollment and Effective Date of Coverage 10-4
reason for declining enrollment; and you get Effective Dates ofoonmragm and Waiting Par�x�
����� a��d���� ��. arek�e��hi�d —employees��their
'
adop1�norpbzoemnent|nanth:|patonof Eligible Dependents.
adoption and you submit the applicable
Enrollment Form to Monroe County BOCC
Benefits Office within 3O days nf the date of
the event.
or
8. (f you or your Eligible Dependent(o) |use
coverage under a CHIP or Medicaid due to
loss of eligibility for such coverage or
become o|ig|b|a for the optional state
premium assistance program and you
submit the applicable Enrollment Form to
Monroe County BOCC Benefits Office within
8O days of the date such coverage was .
terminated prthe date you become eligible
for the optional state premium assistance
program.
The Effective Date cf coverage for you and your
Eligible Dependents added aoa result ofm
special enrollment event|e the date ofthe
special enrollment event. Eligible Employees or
Eligible Dependents who do not enroll wrchange
their coverage selection during the Special
Enrollment Period must wait until the next
Annual Open Enrollment Period (See the
Dependent Enrollment subsection of this section
for the rules relating to the enrollment ofEligible
Dependents ofa Covered Plan Partio|pent).
Other Provisions Regarding
Enrollment and Effective Date of
Coverage
Rehired Employees
Individuals who are rehired am employees of
Monroe County BOCC or any cfthe
Constitutional Officers or their Employees are
considered newly hired employees for purposes
of this section. The provisions of the Group
Health Plan (which includes this Bonh|md which
are applicable to newly hired employees and
their Eligible Dependents(o.g.. enrollment,
Enrollment and Effective Date mCoverage 10-6
Section 11: Termination of Coverage
Termination of a Covered Plan 4. last day of the Calendar Year that the
Participant's Coverage Covered Dependent child no longer meets
any of the applicable eligibility requirements;
A Covered Plan Participant's coverage under
this Benefit Booklet will automatically terminate 5• date specified by Monroe County BOCC that
at 12:01 a.m.: the Dependent's coverage is terminated for
cause(see the Termination of Individual
1, on the date the Group Health Plan Coverage for Cause subsection).
terminates;
In the event you as the Covered Plan Participant
2. on the date the ASO Agreement between wish to delete a Covered Dependent from
BCBSF and Monroe County BOCC coverage, an Enrollment Form must be
terminates; forwarded to BCBSF through Monroe County
3. on the last day of the first month that the BOCC Benefits Office.
Covered Plan Participant fails to continue to In the event you as the Covered Plan Participant
meet any of the applicable eligibility wish to terminate a spouse's coverage, (e.g., in
requirements; the case of divorce)
you must submit an
4. on the date specified by Monroe County Enrollment Form to Monroe County BOCC, prior
BOCC that the Covered Plan Participant's to the requested termination date or within 10
coverage is terminated for cause (see the days of the date the divorce is final, whichever is
Termination of an Individual Coverage for applicable.
Cause subsection); or
5. on the date specified by Monroe County Termination of an Individual's
BOCC that the Covered Plan Participant's Coverage for Cause
coverage terminates. In the event any of the following occurs, Monroe
Termination of a Covered County BOCC may terminate an individual's
Dependent's Coverage coverage for cause:
1. fraud, material misrepresentation or
A Covered Dependent's coverage will omission in applying for coverage or
automatically terminate at 12:01 a.m. on the benefits; or
date: 2. the knowing misrepresentation, omission or
1. the Group Health Plan terminates; the giving of false information on Enrollment
Forms or other forms completed, by or on
2. the Covered Plan Participant's coverage your behalf.
terminates for any reason;
3. the Dependent becomes covered under an Notice of Termination
alternative health benefits plan which is
offered through or In connection with the It is Monroe County BOCC's responsibility to
Group Health Plan; immediately notify you of your termination or that
of your Covered Dependents for any reason.
Terminadon of Coverage
f'-1
Certification of Creditable Coverage
In the event coverage terminates for any reason,
a written certification of Creditable Coverage will
be issued to you.
The certification of Creditable Coverage will
indicate the period of time you were enrolled
under Monroe County BOCC's Group Health
Plan. Creditable Coverage may reduce the
length of any Pre-existing Condition
exclusionary period by the length of time you
had prior Creditable Coverage.
Upon request, another certification of Creditable
Coverage will be sent to you within 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.
The succeeding carrier will be responsible for
determining if coverage meets the qualifying
Creditable Coverage guidelines(e.g., no more
than a 63-day break in coverage).
Termination of Coverage
11.2
Section 12: Continuing Coverage Under COBRA
A federal continuation of coverage law, known months) if you or your Covered
as the Consolidated Omnibus Budget Dependent(s) is/are totally disabled (as
Reconciliation Act of 1985(COBRA), as defined by the Social Security Administration'
amended, may apply to your Group Health Plan. (SSA)) at the time of your termination,
If COBRA applies, you or your Covered reduction in hours or within the first 60 days
Dependents may be entitled to continue of COBRA continuation coverage. The
coverage for a limited period of time, if you meet Covered Person must supply notice of the
the applicable requirements, make a timely disability determination to Monroe County
election, and pay the proper amount required to BOCC Benefits Office within 18 months of
maintain coverage. becoming eligible for continuation coverage
You must contact Monroe County BOCC and no later than 60 days after the SSA's
Benefits Office to determine if you or your determination date.
Covered Dependent(s)are entitled to COBRA 2. Your Covered Dependent(s) may elect to
continuation of coverage. Monroe County continue their coverage for a period not to
BOCC is solely responsible for meeting all of the exceed 36 months in the case of:
obligations under COBRA, including the
obligation to notify all Covered Persons of their a) the Covered Plan Participant's
rights under COBRA, If you fail to meet your entitlement to Medicare;
obligations under COBRA and this Benefit b) divorce or legal separation of the
Booklet, Monroe County BOCC will not be liable Covered Plan Participant;
for any claims incurred by you or your Covered c) death of the Covered Plan Participant;
Dependent(s) after termination of coverage.
A summary of your COBRA rights and the d) the employer files bankruptcy(subject to
general conditions for qualification for COBRA bankruptcy court approval); or
continuation coverage is provided below. e) a dependent child may elect the 36
The following is a summary of what you may month extension if the dependent child
elect, if COBRA applies to Monroe County ceases to be an Eligible Dependent
BOCC and you are eligible for such coverage: under the terms of Monroe County
BOCC s coverage,
1. You may elect to continue this coverage for Children born to or placed for adoption with the
a period not to exceed 18 months*in the Covered Plan Participant during the continuation
case of:
coverage periods noted above are also eligible
a) termination of employment of the for the remainder of the continuation period.
Covered Plan Participant other than for Additional requirements applicable to
gross misconduct; or continuation of coverage under COBRA are set
b) reduced hours of employment of the forth below:
Covered Plan Participant. 1. Monroe County BOCC must notify you of
*Note; You and/or your Covered your continuation of coverage rights under
Dependent(s) are eligible for an 11 month COBRA within 14 days of the event which
extension of the 18 month COBRA creates the continuation option. If coverage
continuation option above(to a total of 29 would be lost due to Medicare entitlement,
Condnuing Coverage Under COBRA
12.1
divorce, legal separation or the failure of a An election by a Covered Plan Participant or
Covered Dependent child to meet eligibility Covered Dependent spouse shall be deemed to
requirements,you or your Covered be an election for any other qualified beneficiary
Dependent must notify Monroe County related to that Covered Plan Participant or
BOCC Benefits Office, in writing, within 60 Covered Dependent spouse, unless otherwise
days of any of these events. Monroe specified in the election form.
County BOCC's 14-day notice requirement Note: This section shall not be Interpreted to
runs from the date of receipt of such notice. grant any continuation rights In excess of
2. You must elect to continue the coverage those required by COBRA and/or Section
within 60 days of the later of: 4980B of the Internal Revenue Code.
a) the date that the coverage terminates; or Additionally,this Benefit Booklet shall be
deemed to have been modified, and shall be
b) the date the notification of continuation of Interpreted, so as to comply with COBRA
coverage rights is sent by Monroe and changes to COBRA that are mandatory
County BOCC. with respect to Monroe County BOCC.
3. COBRA coverage will terminate if you
become covered under any other group
health insurance plan. However, COBRA
coverage may continue if the new group
health insurance plan contains exclusions or
limitations due to a Pre-existing Condition
that would affect your coverage.
4. COBRA coverage will terminate if you
become entitled to Medicare.
5. If you are totally disabled and eligible and
elect to extend your continuation of
coverage, you may not continue such
extension of coverage more than 30 days
after a determination by the Social Security
Administration that you are no longer
disabled. You must inform Monroe County
BOCC Benefits Office of the Social Security
Administration's determination within 30
days of such determination.
6. You must meet all contribution
requirements, and all other eligibility
requirements described in COBRA, and,to
the extent not inconsistent with COBRA, in
the Group Health Plan.
7. COBRA coverage will terminate on the date
Monroe County BOCC ceases to provide
group health coverage to its employees.
Conflnuing Coverage Under COBRA 12-2
Section 13: Conversion Privilege
Eligibility Criteria for Conversion Additionally, you are not entitled to a converted
You are entitled to apply for a BCBSF individual policy if:
insurance conversion policy(hereinafter referred 1. you are eligible for or covered under the
to as a"converted policy"or"conversion policy") Medicare program;
if:
2. you failed to pay, on a timely basis,the
1. you were continuously covered for at least contribution required for coverage under the
three months under the Group Health Plan, Group Health Plan;
and/or under another group policy that
provided similar benefits immediately prior to 3. the Group Health Plan was replaced within
the Group Health Plan; and 31 days after termination by any group
2. your coverage was terminated for any policy, contract, plan, or program, including
reason, including discontinuance of the a self-insured plan or program, that provides
Group Health Plan in its entirety and benefits similar to the benefits provided
termination of continued coverage under under this Booklet; or
COBRA. 4. a) you fall under one of the following
Notify BCBSF in writing or by telephone if you categories and meet the requirements of
are interested in a conversion policy. Within 14 4.b. below:
days of such notice, BCBSF will send you a 1. you are covered under any Hospital,
conversion policy application, premium notice surgical, medical or major medical
and outline of coverage. The outline of policy or contract or under a
coverage will contain a brief description of the prepayment plan or under any other
benefits and coverage, exclusions and plan or program that provides
limitations, and the applicable Deductible(s) and benefits which are similar to the
Coinsurance provisions. benefits provided under this Booklet;
BCBSF must receive a completed application or
for a converted policy,and the applicable ii. you are eligible, whether or not
premium payment,within the 63-day period covered, under any arrangement of
beginning on the date the coverage under coverage for individuals in a group,
the Group Health Plan terminated. If whether on an insured, uninsured,
coverage has been terminated, due to the or partially insured basis,for
non-payment of employee contribution by benefits similar to those provided
Monroe County BOCC, BCBSF must receive under this Booklet; or
the completed converted policy application
and the applicable premium payment within ill. benefits similar to the benefits
the 63-day period beginning on the date provided under this Booklet are
notice was given that the Group Health Plan provided for or are available to you
terminated. pursuant to or in accordance with
In the event BCBSF does not receive the the requirements of any state or
converted policy application and the initial federal law(e.g., COBRA,
premium payment within such 63-day period, Medicaid); and
your converted policy application will be denied
and you will not be entitled to a converted policy.
Conversion Privilege 13-1
.............. ....................... ............ ...........................................
b) the benefits provided under the sources
referred to in paragraph 4.a.i or the
benefits provided or available under the
source referred to in paragraph 4.a.ii.
and 4.a.iii. above,together with the
benefits provided by our converted
policy would result in over-insurance in
accordance with our over-insurance
standards, as determined by us.
Neither Monroe County BOCC nor BCBSF
has any obligation to notify you of this
conversion privilege when your coverage
terminates or at any other time. It is your
sole responsibility to exercise this
conversion privilege by submitting a BCBSF
converted policy application and the initial
premium payment to us within 63 days of the
termination of your coverage under this
Benefit Booklet. The converted policy may
be issued without evidence of Insurability
and shall be effective the day following the
day your coverage under this Benefit Booklet
terminated.
Note: Our converted policies are not a
continuation of coverage under COBRA or any
other states' similar laws. Coverage and
benefits provided under a converted policy will
not be identical to the coverage and benefits
provided under this Booklet. When applying for
our converted policy, you have two options: 1) a
converted policy providing major medical
coverage meeting the requirements of
627.6675(10) Florida Statutes or 2) a converted
policy providing coverage and benefits identical
to the coverage and benefits required to be
provided under a small employer standard
health benefit plan pursuant to Section
627.6699(12) Florida Statutes. In any event,we
will not be required to issue a converted policy
unless required to do so by Florida law. We
may have other options available to you. Call
the telephone number on your Identification card
for more information.
Conversion Privilege 13-2
Section 14: Extension of Benefits
Extension of Benefits perform those normal day-to-day activities
which you would otherwise perform and you
In the event the Group Health Plan is require regular care and attendance by a
terminated, coverage will not be provided under Physician.
this Benefit Booklet for any Service rendered on 2. In the event you are receiving covered
or after the termination date. The extension of dental treatment as of the termination date
benefits provisions described below only apply of the Group Health Plan a limited extension
when the entire Group Health Plan is of such covered dental treatment will be
terminated. The extension of benefits described provided under this Benefit Booklet if:
in this section do not apply when your coverage
terminates if the Group Health Plan remains in a) a course of dental treatment or dental
effect. The extension of benefits provisions are procedures were recommended in
subject to all of the other provisions, including writing and commenced in accordance
the limitations and exclusions. with the terms specified herein while you
Note: It is your sole responsibility to provide were covered under the Group Health
acceptable documentation showing that you are Plan;
entitled to an extension of benefits. b) the dental procedures were procedures
for other than routine examinations,
1. In the event you are totally disabled on the prophylaxis, x-rays, sealants, or
termination date of the Group Health Plan as orthodontic services; and
a result of a specific Accident or illness
incurred while you were covered under this c) the dental procedures were performed
Booklet, as determined by us, a limited within 90 days after the Group Health
extension of benefits will be provided under Plan terminated.
this Benefit Booklet for the disabled This extension of benefits is for Covered
individual only. This extension of benefits is Services necessary to complete the
for Covered Services necessary to treat the dental treatment only. This extension of
disabling Condition only. This extension of benefits will automatically terminate at
benefits will only continue as long as the the end of the 90-day period beginning
disability is continuous and uninterrupted. In on the termination date of the Group
any event, this extension of benefits will Health Plan or on the date you become
automatically terminate at the and of the 12- covered under a succeeding insurance,
month period beginning on the termination health maintenance organization or self-
date of the Group Health Plan. insured plan providing coverage or
For purposes of this section, you will be Services for similar dental procedures.
considered "totally disabled" only if, in our You are not required to be totally
or Monroe County BOCC's opinion, you are disabled in order to be eligible for this
unable to work at any gainful job for which extension of benefits.
you are suited by education, training, or Please refer to the Dental Care category of
experience, and you require regular care the 'What Is Covered?"section for a
and attendance by a Physician. You are description of the dental care Services
totally disabled only if, in our or Monroe covered under this Booklet.
County BOCC's opinion,you are unable to
Extension of Benefits f 4"'1
3. In the event you are pregnant as of the
termination date of the Group Health Plan, a
limited extension of the maternity expense
benefits included in this Booklet will be
available, provided the pregnancy
commenced while the pregnant individual
was covered under the Group Health Plan,
as determined by us or Monroe County
BOCC. This extension of benefits is for
Covered Services necessary to treat the
pregnancy only. This extension of benefits
will automatically terminate on the date of
the birth of the child. You are not required to
be Totally Disabled In order to be eligible for
this extension of benefits.
Extension of Benefits 14-2
..........
Section 15: The Effect of Medicare Coverage/Medicare
Secondary Payer Provisions
When you become covered under Medicare and disability whose employer has less than 100
continue to be eligible and covered under this employees, retirees and/or their spouses over
Benefit Booklet, coverage under this Benefit the age of 65). Also, if coverage under this
Booklet will be primary and the Medicare Benefit Booklet was primary prior to ESRD
benefits will be secondary, but only to the extent entitlement,then coverage hereunder will
required by law. In all other instances, coverage remain primary for the ESRD coordination
under this Benefit Booklet will be secondary to period. If you become eligible for Medicare due
any Medicare benefits. To the extent the to ESRD, coverage will be provided, as
benefits under this Benefit Booklet are primary, described in this section, on a primary basis for
claims for Covered Services should be filed with 30 months.
BCBSF first.
Disabled Active Individuals
Under Medicare, Monroe County BOCC MAY
NOT offer, subsidize, procure or provide a If you are entitled to Medicare coverage
Medicare supplement policy to you. Also, because of a disability other than ESRD,
Monroe County BOCC MAY NOT induce you to Medicare benefits will be secondary to the
decline or terminate your group health insurance benefits provided under this Benefit Booklet
coverage and elect Medicare as primary payer. provided that:
If you become 65 or become eligible for Monroe County BOCC employed at least 100 or
Medicare due to End Stage Renal Disease more full-time or part-time employees on 50%or
("ESRD"), you must immediately notify Monroe more of its regular business days during the
County BOCC Benefits Office. previous Calendar Year. If the Group Health
Individuals With End Stage Renal Plan is a multi-employer plan, as defined by
Medicare, Medicare benefits will be secondary if
Disease at least one employer participating in the plan
If you are entitled to Medicare coverage covered 100 or more employees under the plan
because of ESRD, coverage under this Benefit on 50%or more of its regular business days
Booklet will be provided on a primary basis for during the previous Calendar Year.
30 months beginning with the earlier of: Miscellaneous
1. the month in which you became entitled to
Medicare Part "A" ESRD benefits; or 1. This section shall be subject to, modified (if
necessary) to conform to or comply with,,
2, the first month in which you would have and interpreted with reference to the
been entitled to Medicare Part"A" ESRD requirements of federal statutory and
benefits if a timely application had been regulatory Medicare Secondary Payer
made. provisions as those provisions relate to
If Medicare was primary prior to the time you Medicare beneficiaries who are covered
became eligible due to ESRD,then Medicare under this Benefit Booklet.
will remain primary(i.e., persons entitled due to
The Effect of Medicare Coverage/Medicare Secondary Payer Provisions 115-1
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
this section.
The Effect of Medicare Coverage/Medicare Secondary Payer Provisions 15-2
Section 16: Duplication of Coverage Linder Other Health
Plans/Programs
Coordination of Benefits with which the law permits coordination of
benefits;
Coordination of Benefits("COB") is a limitation
of coverage and/or benefits to be provided under 4. Medicare, as described in "The Effect of
this Benefit Booklet. Medicare Coverage/Medicare Secondary
Payer Provisions"section; and
COB determines the manner in which expenses
will be paid when you are covered under more 5. to the extent permitted bylaw, any other
than one health plan, program, or policy government sponsored health insurance
providing benefits for Health Care Services. program.
COB is designed to avoid the costly duplication The amount of payment, if any, when benefits
of payment for Covered Services. It is your are coordinated under this section, is based on
responsibility to provide BCBSF and Monroe whether or not the benefits under this Benefit
County BOCC Benefits Office information Booklet are primary. When primary, payment
concerning i any duplication of coverage under will be made for Covered Services without
any other health plan, program, or policy you or regard to coverage under other plans. When the
your Covered Dependents may have. This benefits under this Benefit Booklet are not
means you must notify BCBSF and Monroe primary, payment for Covered Services may be
County BOCC Benefits Office in writing if you reduced so that total benefits under all your
have other applicable coverage or if there is no plans will not exceed 100 percent of the total
other coverage. You may be requested to reasonable expenses actually incurred for
provide this information at initial enrollment, by Covered Services. For purposes of this section,
written correspondence annually thereafter, or in in the event you receive Covered Services from
connection with a specific Health Care Service an In-Network Provider or an Out-of-Network
you receive. If the information is not received, Provider who participates in the Traditional
claims may be denied and you will be Program, "total reasonable expenses" shall
responsible for payment of any expenses related mean the total amount required to be paid to the
to denied claims. Provider pursuant to the applicable agreement
Health plans, programs or policies which may be BCBSF or another Blue Cross and/or Blue
subject to COB include, but are not limited to, Shield organization has with such Provider. In
the following which will be referred to as the event that the primary payer's payment
"plan(s)" for purposes of this section: exceeds the Allowed Amount, no payment
will be made for such Services.
1. any group or non-group health insurance,
group-type self-insurance, or HMO plan; The following rules shall be used to establish the
order in whiich benefits under the respective
2. any group plan issued by any Blue Cross plans will be determined:
and/or Blue Shield organization(s);
1. When you are covered as a Covered
3. any other plan, program or insurance policy, Dependent and the other plan covers you as
including an automobile PIP insurance
policy and/or medical payment coverage
Duplication of Coverage Under Other Health Plans/Programs t g.fi
other than a dependent,the Group Health 5. When rules 1, 2, 3, and 4 above do not
Plan will be secondary. establish an order of benefits,the plan which
2. When the Group Health Plan covers a has covered you the longest shall be
dependent child whose parents are not primary.
separated or divorced: The Group Health Plan will not coordinate
benefits against an indemnity-type policy, an
a) the plan of the parent whose birthday, excess insurance policy, a policy with
excluding year of birth, falls earlier in the coverage limited to specified illnesses or
year will be primary; or accidents, or a Medicare supplement policy.
b) if both parents have the same birthday, 6. If you are covered under a COBRA
excluding year of birth, and the other continuation plan as a result of the purchase
plan has covered one of the parents of coverage as provided under the
longer than us, the Group Health Plan Consolidated Omnibus Budget
will be secondary. Reconciliation Act of 1985, as amended,
3. When the Group Health Plan covers a and also under another group plan, the
dependent child whose parents are following order of benefits applies:
separated or divorced: a) first,the plan covering the person as an
a) if the parent with custody is not employee, or as the employee's
remarried, the plan of the parent with Dependent; and
custody is primary; b) second, the coverage purchased under
b) if the parent with custody has remarried, the plan covering the person as a former
the plan of the parent with custody is employee, or as the former employee's
primary; the stepparent's plan is Dependent provided according to the
secondary; and the plan of the parent provisions of COBRA.
without custody pays last; 7. If the other plan does not have rules that
c) regardless of which parent has custody, establish the same order of benefits as
whenever a court decree specifies the under this Booklet, the benefits under the
parent who is financially responsible for other plan will be determined primary to the
the child's health care expenses, the benefits under this Booklet.
plan of that parent is primary.
Coordination of benefits shall not be permitted
4. When the Group Health Plan covers a against an indemnity-type policy, an excess
dependent child and the dependent child is insurance policy as defined in Florida Statutes
also covered under another plan: Section 627.635, a policy with coverage limited
a) the plan of the parent who is neither laid to specified illnesses or accidents, or a Medicare
off nor retired will be primary; or supplement policy.
b) if the other plan is not subject to this Non-Duplication of Government
rule, and if, as a result, such plan does Programs and Worker's
not agree on the order of benefits,this Compensation
paragraph shall not apply.
The benefits under this Booklet shall not
duplicate any benefits to which you or your
Duplicatlon of Coverage Under Other Health Plans/Programs 16_2
Covered Dependents are entitled to or eligible
for under government programs (e.g., Medicare,
Medicaid, Veterans Administration)or Worker's
Compensation to the extent allowed by law, or
under any extension of benefits of coverage
under a prior plan or program which may be
provided or required by law.
Duplication of Coverage Under Other Health Plans/Programs 16-3
Section 17: Subrogation
In the event payment is made under this Benefit legal representative shall promptly notify BCBSF
Booklet to you or on your behalf for any claim in in writing of any settlement negotiations prior to
connection with or arising from a Condition entering into any settlement agreement, shall
resulting, directly or indirectly, from an disclose to BCBSF any amount recovered from
intentional act or from the negligence or fault of any person or entity that may be liable, and shall
any third person or entity, Monroe County BOCC not make any distributions of settlement or
and/or the Group Health Plan, to the extent of judgement proceeds without Monroe County
any such payment, shall be subrogated to all BOCC's prior written consent. No waiver,
causes of action and all rights of recovery you release of liability, or other documents executed
have against any person or entity. Such by you without such notice to BCBSF shall be
subrogation rights shall extend and apply to any binding upon Monroe County BOCC.
settlement of a claim, regardless of whether
litigation has been initiated. BCBSF may
recover, on behalf of Monroe County BOCC
and/or the Group Health Plan,the amount of any
payments made on your behalf minus BCBSF or
Monroe County BOCC's pro rata share for any
costs and attorney fees incurred by you in
pursuing and recovering damages. BCBSF may
subrogate, on behalf of Monroe County BOCC
and/or the Group Health Plan,against all money
recovered regardless of the source of the money
Including, but not limited to, uninsured motorist
coverage. Although Monroe County BOCC
may, but is not required to, take into
consideration any special factors relating your
specific case in resolving the subrogation claim,
Monroe County BOCC will have the first right of
recovery out of any recovery or settlement
amount you are able to obtain even if you or
your attorney believes that you have not been
made whole for your losses or damages by the
amount of the recovery or settlement.
You must promptly execute and deliver such
instruments and papers pertaining to such
settlement of claims, settlement negotiations, or
litigation as may be requested by BCBSF or
Monroe County BOCC, and shall do whatever is
necessary to enable BCBSF or Monroe County
BOCC to exercise Monroe County BOCC's
subrogation rights and shall do nothing to
prejudice such rights. Additionally, you or your
Subrogabon
17.1
Section 18: Right of Reimbursement
If any payment under this Benefit Booklet is
made to you or on your behalf with respect to
any injury or illness resulting from the intentional
act, negligence, or fault of a third person or
entity, Monroe County BOCC and/or the Group
Health Plan will have a right to be reimbursed by
you (out of any settlement or judgment proceeds
you recover) one dollar($1.00)for each dollar
paid under the terms of the Group Health Plan
minus a pro rata share for any costs and
attorney fees incurred in pursuing and
recovering such proceeds.
Monroe County BOCC's and/or the Group
Health Plan's right of reimbursement will be in
addition to any subrogation right or claim
available to Monroe County BOCC, and you
must execute and deliver such instruments or
papers pertaining to any settlement or claim,
settlement negotiations, or litigation as may be
requested by BCBSF on behalf of Monroe
County BOCC, and/or the Group Health 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
Health Plan's right of reimbursement hereunder
and no waiver, release of liability, or other
documents executed by you, without notice to us
and our written consent, acting on behalf of
Monroe County BOCC, will be binding upon
Monroe County BOCC.
Right of Reimbursement 1p
Section 19: Claims Processing
Introduction Post-Service Claims
This section is intended to: How to File a Post-Service Claim
• help you understand what you or your We have defined and described the three types
treating Providers must do, under the terms of claims that may be submitted to us. Our
of this Benefit Booklet, In order to obtain experience shows that the most common type of
payment for expenses for Covered Services claim we will receive from you or your treating
they have rendered or will render to you; Providers will likely be Post-Service Claims.
and
In-Network Providers have agreed to file Post-
provide you with a general description of the Service Claims for Services they render to you.
applicable procedures we will use for In the event a Provider who renders Services to
making Adverse Benefit Determinations, you does not file a Post-Service Claim for such
Concurrent Care Decisions and for notifying Services, it is your responsibility to file it with us.
you when we deny benefits. We must receive a Post-Service Claim within 901
Under no circumstances will we be held days of the date the Health Care Service was
responsible for, nor will we accept liability rendered or, if it was not reasonably possible to
relating to,the failure of your Group Plan's file within such 90-day period, as soon as
sponsor or plan administrator to: 1)comply with possible. In any event, no Post-Service Claim
any applicable disclosure requirements; will be considered for payment if we do not
2) provide you with a Summary Plan Description receive it at the address indicated on your ID
(SPD); or 3)comply with any other legal Card within one year of the date the Service was
requirements. You should contact your plan rendered unless you were legally incapacitated.
sponsor or administrator if you have questions For Post-Service Claims, we must receive an
relating to your Group Plan's SPD. We are not itemized statement from the health care Provider
your Group Plan's sponsor or plan administrator. for the Service rendered along with a completed
In most cases, a plan's sponsor or plan claim form. The itemized statement must
administrator is the employer who establishes contain the following information:
and maintains the plan. 1. the date the Service was provided;
Types of Claims 2. a description of the Service including any
For purposes of this Benefit Booklet, there are applicable procedure code(s);
three types of claims: 1) Pre-Service Claims; 3. the amount actually charged by the
2) Post-Service Claims; and 3) Claims Involving Provider;
Urgent Care. It is important that you become 4. the diagnosis including any applicable
familiar with the types of claims that can be diagnosis code(s);
submitted to us and the timeframes and other
requirements that apply. b. the Provider's name and address;
6. the name of the individual who received the
Service„ and
Claims Processing 19-1
7. the Covered Plan Participant's name and claim or a portion of the claim is contested. Our
contract number as they appear on the ID notice may identify: 1)the contested portion or
Card. portions of the claim; 2)the reason(s)for
The itemized statement and claim form must be contesting the claim or a portion of the claim;
received by us at the address indicated on your and 3)the date that we reasonably expect to
I D Card. notify you of the decision. The notice may also
indicate whether additional information is
Note: Special claims processing rules may needed in order to complete processing of the
apply for Health Care Services you receive claim. If we request additional information, we
outside the state of Florida under the BlueCard must receive it within 45 days of our request for
Program (See the "BlueCard(Out-of-State) the information, If we do not receive the
Program"section of this Booklet). requested information,the claim or a portion
The Processing of Post-Service Claims of the claim will be adjudicated based on the
Information in our possession at the time
We will use our best efforts to pay, contest, or and may be denied. Upon receipt of the
deny all Post-Service Claims for which we have requested information, we will use our best
all of the necessary information, as determined efforts to complete the processing of the Post-
by us. Post-Service Claims will be paid, Service Claim within 15 days of receipt of the
contested, or denied within the timeframes information.
described below. • Denial of Post-Service Claims
• Payment for Post-Service Claims in the event we deny a Post-Service Claim
When payment is due under the terms of this submitted electronically, we will use our best
Benefit Booklet, we will use our best efforts to efforts to provide notice, within 20 days of
pay(in whole or in part)for electronically receipt, that the claim or a portion of the claim is
submitted Post-Service Claims within 20 days of denied. In the event we deny a paper Post-
receipt. Likewise, we will use our best efforts to Service Claim, we will use our best efforts to
pay(in whole or in part)for paper Post-Service provide notice, within 30 days of receipt, that the
Claims within 40 days of receipt. You may claim or a portion of the claim is denied. The
receive notice of payment for paper claims notice may identify the denied portion(s) of the
within 30 days of receipt. If we are unable to claim and the reason(s)for denial. It is your
determine whether the claim or a portion of the responsibility to ensure that we receive all
claim is payable because we need more or information determined by us as necessary to
additional information, we may contest the claim adjudicate a Post-Service Claim. If we do not
within the timeframes set forth below. receive the necessary information,the claim
• Contested Post-Service Claims or a portion of the claim may be denied.
A Post-Service Claim denial is an Adverse
In the event we contest an electronically Benefit Determination and is subject to the
submitted Post-Service Claim, or a portion of Adverse Benefit Determination standards and
such a claim, we will use our best efforts to appeal procedures described in this section.
provide notice, within 20 days of receipt, that the
claim or a portion of the claim is contested. In Additional Processing Information for Post-
the event we contest a Post-Service Claim Service Claims
submitted on a paper claim form, or a portion of In any event, we will use our best efforts to pay
such a claim, we will use our best efforts to or deny all: 1)electronic Post-Service Claims
provide notice, within 30 days of receipt, that the within 90 days of receipt of the completed claim;
Clalms Processing 19-2
and 2) Post-Service paper claims within 120 Benefit Determinations on Pre-Service Claims
days of receipt of the completed claim. Claims
processing shall be deemed tm have been
oomnp|etadaoof the date the notice of the claims �m'apna'Bon/ioe(�|aim |nvp|vingUrQent<��no.
womi
den|a|oniedepoo�od |n the nnaUbvuaor Uumanu'beat��mdmtopn�vid� nodo�of
^ our determination (�hedh�r�dwmrommrnod
nthenmioe electronically transmitted. Any claims ` ' qm
p�mo��|oUnQtoa�o����om Claim that|a ��nu�p���|�. b�n�d|������ �� huu�
not nmodmbyuawbhin the applicable bmefmamo a�ern�oaptofthepro'G�nHooC1�|mun|oma
additional�ona| informadionionnquirodfor�omwym�Qo
decision. |foddibmn�| informoti�nimneoeoa
the rate established by the F|oddaInsurance �'y
Code. tu make a determination, wm will use our best
efforts bo provide notice within 24 hours of: 1)
VVe will investigate any allegation ofimproper the need for additional information; 2\the
bU|ingbya Provider upon receipt nfvvd� 0
on opw� cinformation that you oryour 'nzvidar
notification from you. |fwm determine that you may need to provide; and 31 the date that vve
were billed for a Service that was not actually reasonably expect tm provide notice ofthe
performed, any payment amount will beadjusted decision. |fwm request additional information,
and, if applicable, a refund will berequested. In vve must receive it within 48 hours ofour
such a case, |f payment to the Provider io request. VVe will use our best efforts toprovide
reduced due solely to the notification from you, notice of the decision on your Pre-Service Claim
wo will pay you 2D percent nfthe amount ofthe within 48 hours after the earlier of: 1) receipt of
reduction, uptom total of$50O' the requested information; or2)the end nfthe
Pre-Service Claims period you were afforded to provide the
specified additional information oedescribed
How to File a Pre-Service Claim above.
This Benefit Booklet may condition coverage, Benefit Determinations on Pre-Service Claims
benefits, ur payment(in whole orinpart\.for a that Do Not Involve Uraent Care
specific Covered Service, on the receipt bvugof VVe will use our best efforts to provide notice ofm
a prs+8on/ioe C|oinn aa that term is defined decision on a Pre-Service Claim not involving
herein. |n order to determine whether wmmust urgent care within 16 days of receipt provided
receive a Pre-Service Claim for a particular additional information is not required for a
Covered Service, please refer to the'What|o coverage decision, This 15'daydetermination
Covarmd?"section and other applicable sections period may be extended byum one time for upto
pf this Benefit Booklet, You may also call the on additional 15days. |f such an extension im
customer service number on your |D card for necessary, wm will use our best efforts toprovide
assistance. notice of the extension and reasons for it. We
VVo are not required to render on opinion pr will use our best efforts to provide notification of
the decision on your Pre-Service claim vvith|na
mak���ov�mag� orbome�kdaharm|nsdimnv�th
bdo| of3Odayooftho |nida| raooiptofthan|a|m
neope��to��en/imathedh�encda�uaUybaen '
v uo
provided tmyou unless the terms ofthis Benefit
|fane��ens|unof time was taken ��b~ '
Booklet require (or condition payment upon) |f additional information im necessary to make a
approval byus for the Service before itis determination, wo will use our best efforts to:
received. 1) provide notice qf the need for additional
information, prior bz the expiration of the initial
15'daypariod; 2) identify the specific information
Claims Processing 19-3
that you or your Provider may need boprovide; Reauests for Extension of Services
and 3) inform you of the date that we reasonably
���n���u�uurde�on. |f� YmrP��rr��qu�� *�n�on �
request additional information, we must receive coverage or benefits for o Service beyond the
|t within 45 days of our request for the approved period of time or number ofapproved
information. VVe will use our best efforts to Services. |f the request for an extension |o for a
provide notification of the decision on your Pre- Claim Involving Urgent Care, we will use our
Service Claim within 15 days mf receipt ofthe best efforts bo notify you ofthe approval or
requested information. denial of such requested extension within 24
hours after receipt ofyour nwquest, provided it is
A Pre-Service Claim denial is on Adverse received at least 24 hours prior tothe expiration
Benefit Determination and ie subject tothe of the previously approved number or length of
Adverse Benefit Determination standards and coverage for such Services. VVo will use our
appeal procedures described|n this section. best efforts tm notify you within 24 hours if: 1)we
need additional informadion'information; or �you oryour
Concurrent Care Decisions
representative failed to follow proper procedures
Reduction or Termination of Coveraae or |n your request for an extension. |fwerequest
Benefits for Services additional information, you will have 48 hours tn
/\reduction or termination of coverage or provide the requested information. yyemay
benefits for Services will be considered an notify you orally o'in ««hdng, unless you or your
Adverse Benefit Determination vvhen' nepreman�di»oopen|finaUyrequest that�bain
' writing. A denial wfa request for extension nf
�
we have approved in writing coverage mr Services |e considered unAdverse Benefit
benefits for an ongoing course mf Services to Determination and io subject bo the Adverse
be provided over a period of time ora Benefit Determination review procedure below.
number of Services hmbe rendered; and
w the reduction o,termination occurs before Standards for Adverse Benefit
the end of such previously approved time or Determinations
number ofServices; and Manner and Content of a Notification of an~ the reduction or termination of coverage mr Adverse Benefit Determination:
benefits byua was not due bzan
We
omdU use our best effodato provide notice of
any Adverse Benefit Determination inwriting.
termination of your coverage am provided by
this Benefit Booklet. Notification of an Adverse Benefit Determination
will include (or will ba made available to you free
VVo will use our best efforts to notify you ofsuch of charge upon nsqueat):
reduction or termination inadvance so that you
will have a reasonable amount of time bzhave 1' the date the Service or supply was provided;
the reduction or termination reviewed |n 2. the Provider's nome'
vv
accordance iththe Adverse BeneOt '
U
Determination standards and procedures 3' the d� aramount of the claim, ifapplicable;
described below. |nno event shall wobo 4. the diagnosis codes included on the claim
required bo provide more than ana000nab|a (e.g.. |CD'9. DGK8'|V)' including
period of time within which you may develop description of such codes;
your appeal before we actually terminate or
neduc000vmnmgefmrth�Gepvinae. 5' the standardized procedure code induded
on the claim (e.8.. Current Procedural
Claims Processing
I
Terminology), including a description of such Determination. An appeal of an Adverse Benefit
codes; Determination will be reviewed using the review
6. the specific reason or reasons for the process described below. Your appeal must be
Adverse Benefit Determination, including submitted to us in writing for an internal appeal
any applicable denial code; within 365 days of the original Adverse Benefit
Determination, except in the case of Concurrent
7. a description of the specific Benefit Booklet Care Decisions which may, depending upon the
provisions upon which the Adverse Benefit circumstances, require you to file within a
Determination is based, as well as any shorter period of time from notice of the denial.
internal rule, guideline, protocol, or other The following guidelines are applicable to
similar criterion that was relied upon in reviews of Adverse Benefit Determinations:
making the Adverse Benefit Determination; • We must receive your appeal of an Adverse
8. a description of any additional information Benefit Determination in person or in writing;
that might change the determination and • You may request to review pertinent
why that information is necessary; documents, such as any internal rule,
9. a description of the Adverse Benefit guideline, protocol, or similar criterion relied
Determination review procedures and the upon to make the determination, and submit
time limits applicable to such procedures; issues or comments in writing;
10. if the Adverse Benefit Determination is ' If the Adverse Benefit Determination is
based on the lack of Medical Necessity of a
based on the Medical Necessity or particular Service or the Experimental or
Experimental or Investigational limitations Investigational exclusion, you may request,
and exclusions, a statement telling you how free of charge, an explanation of the
to obtain the specific explanation of the scientific or clinical judgment relied upon, if
scientific or clinical judgment for the any, for the determination, that applies the
determination; and terms of this Benefit Booklet to your medical
11. You have the right to an independent circumstances;
external review through an external review • During the review process,the Services in
organization for certain appeals, as provided question will be reviewed without regard to
in the Patient Protection and Affordable the decision reached in the initial
Care Act of 2010. determination;
If the claim is a Claim Involving Urgent Care, we ' We may consult with appropriate
may notify you orally within the proper Physicians, as necessary;
timeframes, provided we follow-up with a written • Any independent medical consultant who
or electronic notification meeting the reviews your Adverse Benefit Determination
requirements of this subsection no later than on our behalf will be identified upon request;
three days after the oral notification. If your claim is a Claim Involving Urgent
How to Appeal an Adverse Benefit Care, you may request an expedited appeal
orally or in writing in which case all
Determination necessary information on review may be
transmitted between you and us by
Except as described below, only you, or a telephone, facsimile or other available
representative designated by you in writing, expeditious method; and
have the right to appeal an Adverse Benefit
Claims Processing
19-5
w If you wish to give someone else permission claim denial. The appeal may be directed to an
to appeal an Adverse Benefit Determination wmo|oy�mof����F�hoio�|k:�no�� Phmm��n
#n your beha� we must reoe�ou ' Physician
responsible for Medical Necessitymawiews The
completed Appointment mfRopmaoen�dive appeal may bebv�m|ophonoandthm �h—~oian
fomnsigned by you indioaUngthe nanneof ' »w/
will
Unaopondtoyou. v�thinaneaomnab|atinna. not
respect bu the appeal. ^4n/4ppo|ntmentoY �oe�c��d1��u�in�m�d���. ������V�y����
Flapnaeenb�ivefomm |onotnaqu|red |fymur y�tem»��m���eys��oy� ��m��t0�������r�w�
below:
Physician io appealing on Adverse Bone�t
Determination relating bzaClaim Involving Blue Cross and Blue Shield of Florida, Inc.
Urgent Care. Appointment of Attention: Member Appeals
Representative forms are available ot p.CJ. Box 44197
orbv calling the Jacksonville, Florida 32Q@1-41S7
number onthe back Pf your BCBSF|D Card.
TImIn_q of Our Ammal Review on Adverse How to Request External Review of
Benefit Determinations Our Appeal Decision
VVe will use our best efforts to review your |fwe deny your appeal and our decision involves
appeal ofan Adverse Benefit Determination and a medical judgment, including, but not limited to,
��
oomrnun|oatathe decision |n accordance wd a decision based onK8edina| ��mneoo
h ^'
the following time fnamos' appnopho1en000. health care se�ing. level of
' care or effectiveness qf the Health Care Service
� Pre-Sen/ioeC|aims—vxithinDOdaysofthe ur treatment you requested oredetermination
receipt of your appeal; or that the treatment io Experimental or
w Post-Service C|aims—within GD days ofthe Investigational, you are entitled to request en
independent, external revimvvof our decision.
rnc�iptnfyou��p���|� or Your request will be reviewed by an independent
w Claims Involving Urgent Care (and requests third party with clinical and legal expertise
to extend concurrent care Services made ("Exb»'na| Re»iewor')who has noassociation
within 24 hours prior to the termination ofthe with us. |f you have any questions orconcerns
8erviooa)—within 72 hours of receipt ofyour during the external review process, please
request. |f additional information |a contact uaed the phone number listed on your|O
necessary wa will notify you within 24hours card orvisit ' You may
and vvn must receive the requested submit additional written comments bmExternal
additional information within 48 hours of our Reviewer. A letter with the mailing address will
request. After vvo receive the additional be sent to you when you file an external review.
information, vws will have on additional 48 Please note that/f you provide any additional
hours tq make a final determination. �
information during the � erna| review process it
will be shared with uain order to give umthe
Note: The nature ofa claim for Services(ie. opportunity to reconsider the denial. Submit
whether it|e"urgent care"or not) io judged amof your request in writing on the External Review
the time of the benefit determination #nreview, Request form within four months after receipt cf
not osof the time the Service was initially your denial to the below address:
reviewed orprovided. Blue Cross and Blue Shield of Florida
You, or Provider acting on your behalf, who Attention: Member External Reviews DC[>9-5
has had a claim denied as not Medically Post Office Box 441S7
Necessary has the opportunity bz appeal the Jacksonville, FL32231-41g7
Claims Processing
If you have a medical Condition where the You may request and we will provide the
timeframe for completion of a standard external diagnosis and treatment codes, as well as their
review would seriously jeopardize your life, corresponding meanings, applicable to this
health or ability to regain maximum function, you notice, if available.
may file a request for an expedited external
review. Generally, an urgent situation is one in Additional Claims Processing
which your health may be in serious jeopardy, or Provisions
in the opinion of your Physician, you may
experience pain that cannot be adequately 1. Release of Information/Cooperation:
controlled while you wait for a decision on the In order to process claims,we may need
external review of your claim. Moreover certain information, including information
expedited external reviews may be requested for regarding other health care coverage you
an admission, availability of care, continued stay
or Health Care Service for which you received may have. You must cooperate with us in
Emergency Services, but have not been our effort to obtain such information by,
discharged from a facility. Please be sure your among other ways, signing any release of
treating Physician completes the appropriate information form at our request. Failure by
form to initiate this request type. If you have any you to fully cooperate with us may result in a
questions or concerns during the external review denial of the pending claim and we will have
process, please contact us at the phone number no liability for such claim.
listed on your ID card or visit 2. Physical Examination:
www.floridablue.com. You may submit
additional written comments to the External In order to make coverage and benefit
Reviewer. A letter with the mailing address will decisions, we may, at our expense, require
be sent to you when you file an external review. you to be examined by a health care
Please note that if you provide any additional Provider of our choice as often as is
information during the external review process it reasonably necessary while a claim is
will be shared with us in order to give us the pending. Failure by you to fully cooperate
opportunity to reconsider the denial. If you with such examination shall result in a denial
believe your situation is urgent, you may request of the pending claim and we shall have no
an expedited review by sending your request to liability for such claim.
the address above or by fax to 904-565-6637. 3. Legal Actions:
If the External Reviewer decides to overturn our
decision, we will provide coverage or payment No legal action arising out of or in
connection with coverage under this Benefit
for your health care item or Service. Booklet may be brought against us within
You or someone you name to act for you may the 60-day period following our receipt of the
file a request for external review. To appoint completed claim as required herein.
someone to act on your behalf, please complete Additionally, no such action may be brought
an Appointment of Representative form. after expiration of the applicable statute of
You are entitled to receive, upon written request limitations.
and free of charge, reasonable access to, and 4. Fraud, Misrepresentation or Omission in
copies of all documents relevant to your appeal Applying for Benefits:
including a copy of the actual benefit provision,
guideline protocol or other similar criterion on We rely on the information provided on the
itemized statement and the claim form when
which the appeal decision was based. processing a claim. All such information,
Clalms Processing
19-7
therefore, must be accurate,truthful and emergency or similar event not within our
complete. Any fraudulent statement, control, results |n facilities, personnel mrour
omission or concealment mffacts, financial resources being unable tnprocess
nn|anopnoaontndion, or incorrect information claims for Covered Omn,ioem, we will have no
may result, in addition to any other legal liability mr obligation for any delay inthe
remedy we may have, in denial of the claim payment of claims for Covered Services,
o,cancellation or rescission ofyour except that we will make a good faith effort
coverage. tm make payment for such Services, taking
6. Explanation of Benefits Form: into account the impact of the event. For the
purposes of this paragraph, an event|anot
All claims decisions, including denial and within our control ifwe cannot effectively
n|e]cna review dooixdono will be. exercise Influence or dominion over its
communicated to you in writing either onan occurrence ornon-000urnanom.
explanation of benefits form or some other
written correspondence. This form may
indicate:
aj The specific reason orreasons for the
Adverse Benefit Determination;
b) Reference to the specific Benefit
Booklet provisions upon which the
Adverse Benefit Determination iobased
as well as any internal nu|e, guidg|ine,
protocol, cv other similar criterion that
was relied upon in making the Adverse
Benefit Determination;
.
o) A description of any additional
information that would change the initial
determination and why that information
is necessary;
d) A description ofthe applicable Adverse
Benefit Determination naViavv
procedures and the time limits
applicable bz such procedures; and
o) |f the Adverse Benefit Determination is
based on the Medical Necessity or
Experimental or|nmamUgcdiona|
limitations and oxo|ueiono, aotaioment
telling you how you can obtain the
specific explanation of the scientific or
clinical judgment for the determination.
G. Circumstances Beyond Our Control:
To the extent that natural dioaater, m/mr, riot,
civil inourneot|on, ep|demin, or other
ola/mopmvesmno
19-o
Section 20: Relationship Between the Parties
BCBSF/Monroe County BOCC and nor Monroe County BOCC will be liable, whether
Health Care Providers in tort or contract or otherwise, for any acts or
omissions of any other person or organization
Neither BCBSF nor Monroe County BOCC nor with which BCBSF has made or hereafter makes
any of their officers, directors or employees arrangements for the provision of Covered
provides Health Care Services to you. Rather, Services. BCBSF is not your agent, servant, or
BCBSF and Monroe County BOCC are engaged representative nor is BCBSF an agent, servant,
in making coverage and benefit decisions under or representative of Monroe County BOCC and
this Booklet. By accepting the Group health BCBSF willl not be liable for any acts or
care coverage and benefits, you agree that omissions, or those of Monroe County BOCC, its
making such coverage and benefit decisions agents, servants, employees, or any person or
does not constitute the rendering of Health Care organization with which Monroe County BOCC
Services and that health care Providers has entered into any agreement or arrangement.
rendering those Services are not employees or By acceptance of coverage and benefits
agents of BCBSF or Monroe County BOCC. In hereunder, you agree to the foregoing,
this regard,we and Monroe County BOCC
hereby expressly disclaim any agency Medical Treatment Decisions -
relationship,actual or implied,with any Responsibility of Your Physician, Not
health care Provider. BCBSF and Monroe BCBSF
County BOCC do not, by virtue of making
coverage, benefit, and payment decisions, Any and alll decisions that require or pertain to
exercise any control or direction over the independent professional medical judgment or
medical judgment or clinical decisions of any training, or the need for medical Services or
health care Provider. Any decisions made under supplies, must be made solely by your family
the Group Health Plan concerning and your treating Physician in accordance with
appropriateness of setting, or whether any the patient/physician relationship. It is possible
Service is Medically Necessary, shall be that you or your treating Physician may conclude
deemed to be made solely for purposes of that a particular procedure is needled,
determining whether such Services are covered, appropriate, or desirable, even though such
and not for purposes of recommending any procedure may not be covered,
treatment or non-treatment. Neither BCBSF nor
Monroe County BOCC will assume liability for
any loss or damage arising as a result of acts or
omissions of any health care Provider.
Non Liability of BCBSF and Monroe
County BOCC
Neither Monroe County BOCC nor any person
covered under this Booklet is BCBSF's agent or
representative, and neither shall be liable for any
acts or omissions by BCBSF's agents, servants,
employees, or us. Additionally, neither BCBSF
Relationship Between the Parties
20-1
Section 21: General Provisions
Access to Information Compliance with State and Federal
BCBSF and Monroe County SOCC have the Laws and Regulations
right to receive,from you and any health care The terms of coverage and benefits to be
Provider rendering Services to you, information provided under this Benefit Booklet shall be
that is reasonably necessary, as determined by deemed to have been modified and shall be
BCBSF and Monroe County BOCC, in order to interpreted, so as to comply with applicable state
administer the coverage and benefits provided, or federal laws and regulations dealing with
subject to all applicable confidentiality benefits, eligibility, enrollment,termination, or
requirements listed below. By accepting other rights and duties.
coverage, you authorize every health care
Provider who renders Services to you, to Confidentiality
disclose to BCBSF and Monroe County BOCC
or to affiliated anti#ies, upon request, all facts, kept as otherwise specifically provided herein,
and except as may be required in order for us to
records, and reports pertaining to your care, administer coverage and benefits, specific
treatment, and physical or mental Condition, and medical information concerning you, received by
to permit BCBSF and/or Monroe County BOCC Providers, shall be kept confidential by us in
to copy any such records and reports so conformity with applicable law. Such information
obtained. may be disclosed to third parties for use in
connection with bona fide medical research and
Right to Receive Necessary education, or as reasonably necessary in
Information connection with the administration of coverage
and benefits, specifically including BCBSF's
In order to administer coverage and benefits, quality assurance and Blueprint for Health
BCBSF or Monroe County BOCC may, without Programs. Additionally, we may disclose such
the consent of, or notice to, any person, plan, or information to entities affiliated with us or other
organization, obtain from any person, plan, or persons or entities we utilize to assist in
organization any information with respect to any providing coverage, benefits or services under
person covered under this Booklet or applicant this Booklet. Further, any documents or
for enrollment which BCBSF or Monroe County information which are properly subpoenaed in a
BOCC deem to be necessary. judicial proceeding, or by order of a regulatory
agency, shall not be subject to this provision.
Right to Recovery BCBSF's arrangements with a Provider may
require that we release certain claims and
Whenever the Group Health Plan has made medical information about persons covered
payments in excess of the maximum provided under this Booklet to that Provider even if
for under this Booklet,BCBSF or Monroe treatment has not been sought by or through
County BOCC will have the right to recover any that Provider. By accepting coverage,you
such payments,to the extent of such excess, hereby authorize us to release to Providers
from you or any person, plan, or other claims information, including related medical
organization that received such payments. information, pertaining to you in order for any
such Provider to evaluate your financial
responsibility under this Booklet.
General Provisions
21-1
Benefit Booklet constitute a waiver of any such terms or
conditions. Further, it will not affect BCBSF's or
You have been provided with this Benefit Monroe County BOCC's right at any time to
Booklet and an Identification Card as evidence enforce any terms or conditions under this
of your coverage under this Benefit Booklet. Benefit Booklet.
Modification of Provider Network and Notices
the Participation Status
Any notice required or permitted hereunder will
NetworkBlue and the Traditional Provider be deemed given if hand delivered or if mailed
Program, and the participation status of by United States Mail, postage prepaid, and
individual Providers available through BCBSF, addressed as listed below. Such notice will be
are subject to change at any time by BCBSF deemed effective as of the date delivered or so
without prior notice to you or your approval or deposited in the mail.
that of Monroe County BOCC. Additionally, If to BCBSF:
BCBSF may, at any time,terminate or modify
the terms of any Provider contract and may To the address printed on the Identification
enter into additional Provider contracts without Card.
prior notice to you, or your approval or that of If to you:
Monroe County BOCC. It is your responsibility
to determine whether a health care Provider is To the latest address provided by you or to
an In-Network Provider at the time the Health your latest address on Enrollment Forms
Care Service is rendered. Under this Booklet, actually delivered to us.
your financial responsibility may vary depending You must notify Monroe County BOCC
upon a Provider's participation status. Benefits Office Immediately of any
Cooperation Required of You and address change.
Your Covered Dependents If to Monroe County BOCC:
To the address indicated by Monroe County
You must cooperate with BCBSF and Monroe BOCC.
County BOCC, and must execute and submit to
us any consents, releases, assignments, and Our Obligations Upon Termination
other documents requested in order to
administer, and exercise any rights hereunder. Upon termination of your coverage for any
Failure to do so may result in the denial of reason, there will be no further liability or
claims and will constitute grounds for termination responsibility to you under the Group Health
for cause(See the Termination of an Individual's Plan, except as specifically described herein.
Coverage for Cause subsection in the
Termination Of Coverage section). Promissory Estoppel
Non-Waiver of Defaults No oral statements, representations, or
understanding by any person can change, alter,
Any failure by BCBSF or Monroe County BOCC delete, add, or otherwise modify the express
at any time, or from time to time, to enforce or to written terms of this Booklet.
require the strict adherence to any of the terms
or conditions described herein, will in no event
General Provislons
21-2
Florida Agency for Health Care
Administration Performance Data
The performance outcome and financial data
published by the Agency for Health Care
Administration (AHCA), pursuant to Florida
Statute 408.05, or any successor statute,
located at the web site address
www.floridahealthfinder.goy, may be accessed
through the link provided on the Blue Cross and
Blue Shield of Florida corporate web site at
www.floridablue.com.
Third Party Beneficiary
The terms and provisions of the Group Health
Plan shall be binding solely upon, and inure
solely to the benefit of, Monroe County BOCC
and individuals covered under the terms of this
Benefit Booklet, and no other person shall have
any rights, interest or claims thereunder, or
under this Benefit Booklet, or be entitled to sue
for a breach thereof as a third-party beneficiary
or otherwise. Monroe County BOCC hereby
specifically expresses its intent that health care
Providers that have not entered into contracts
with BCBSF to participate in BCBSF's Provider
networks shall not be third-party beneficiaries
under the terms of the Monroe County BOCC
Group Health Plan or this Benefit Booklet.
Customer Rewards Programs
From time to time, we may offer programs to our
customers that provide rewards for following the
terms of the program. We will tell you about any
available rewards programs in general mailings,
member newsletters and/or on our website.
Your participation in these programs is
completely voluntary and will in no way affect
the coverage available to you under this Benefit
Booklet. We reserve the right to offer rewards in
excess of$25 per year as well as the right to
discontinue or modify any reward program
features or promotional offers at any time
without your consent.
General Provisions
91-3
�0
4� ~�.
��«�u�K^�K��� ^��,. Definitions
The following definitions are used |n this Benefit 1. In the case o{an In-Network Provider
Booklet. Other definitions may be found |nthe located |n Florida,this amount will be
particular section or subsection where they are established in accordance with the
used.
applicable agreement between that Provider
Accident means an unintentional, unexpected and BCBSF.
event, other than the acute onset ofa bodily 2' In the case ofonIn-Network Provider
infirmity or disease, which results |ntraumatic located outside of Florida, this amount will
injury. This term does not include injuries generally be established in accordance with
caused by surgery or treatment for disease or the negotiated price that the on-site Blue
illness. Cross and/or Blue Shield Plan ("Host Blue")
Accidental Dental UrWmrynmmanoan injury bo passes mn$z us, except when the Host Blue
In
jury
sound natural teeth |o unable to pass on its negotiated price due
(not`compromised by to the terms of its Provider contracts. See
md�c�v4 raum�� bw�oudd�n '
' ^' ' 'unintentional, and unexpected event orforce. thoB|umCand/��ut'o�8toto) ProQnmnn`This term does not include|n]uh oant|onfornnmnodate||emototh� mouth, '
structures within the oral cavity, or injuries to 3' |n the case of Out-of-Network Providers
natural teeth caused bv biting wrchewing, located in Florida who participate |nthe
surgery, or treatment for a disease orillness. Traditional Program, this amount will bm
established in accordance with the
Administrative Services Only Agreement or applicable agreement between that Provider
ASKD Agreement means an agreement between andBCB8F.
Monroe County BOCC and BCBSF. Under the 4. |n the case ofK3ut-of-NobworkProviders
Administrative Services Only Agreement, located outside of Florida who participate in
BCBSF provides claims processing and the B|ueCond/��(Out-of-State)Traditional
paynnentservices, customer service, utilization PvoQnam. th|e` mountwU|—onenaUybo
(�
review services and access hz� BBF's �� � =
established accordance with the
NmbomrhB|uoand BCB8F'a network of
negotiated price that the Host Blue passes
Traditional Insurance Providers.
omto us, except when the Host Blue |a
Adverse Benefit Determination means any unable to pass on its negotiated price due to
denial, reduction or termination ofcoverage, the terms of its Provider contracts. See the
benefits, or payment(in whole or|n part) under EUueCard (Out-of'Stote) Program section for
the Benefit Booklet with respect toaPre-Service more details.
Claim nra Post-Service Claim. Any reduction nr 5. |n the case mfanOut-of-NetmorkProvider
termination of coverage, benefits, or payment|n that has not entered into an agreement with
connection with aConcurrent Care Decision, as BCB@Fbo provide access boadiscount from
described |n this oact|on shall
' the billed amount of that Provider for the
Adverse Benefit Determination.
specific Covered Services provided toyou,
A|y«mxm*d Amount means the maximum amount the Allowed Amount will be the lesser ofthat
upon which payment will ba based for Covered Providers actual billed amount for the
Services. The Allowed Amount may be changed specific Covered Services ormnamount
at any time without notice to you oryour established byBCBSF that may bebased
consent.
on several factors including (but not
oonnmono
�
necessarily limited to): 0payment for such billed by such Out-of-Network Provider for such
Services under the Medicare and/or Services. You will bo responsible for any
Medicaid programs; h|\ payment often difference between such Allowed Amount and
accepted for such Services by that Out-of- the amount billed for such Services by any such
Network Provider and/or by other Providers, Out-of-Network Provider.
either inFlorida orin other comparable Ambulance means a ground or water vehicle,
mnarket(s).that BCBSF determines are airplane or helicopter properly licensed pursuant
comparable to the Out'of-NebworkProvider tm Chapter 401of the Florida Statutes, ora
that provided the specific Covered Services similar applicable law in another state.
(which may include payment accepted bv
nn
munhc�u�o�y�abwod« Provider and/or bv^ � ��Kmt������gUomK ������� meenaafo�i|ih/
oth�rprov|danm�ap�din|pating ^ in pnopedy licensed pursuant to<�hapter3SGofthe
providers Florida Statutes, ora similar applicable law of
other provider networks q{thind-pe�ypayers '
»«hiohmo�ino|ude. fmr�»sanp|e' other another st�e.the primary purpose of which isbm
provide elective surgical care bzopadent
insurance oomnpanieoand/or health '
admitted to, and discharged from such facility
maintenance oqganizationa); (i|i) payment within the same working day.
amounts which are consistent, as
determined byBCBSF. with BCB8F'e Applied Behavior Analysis means the design,
provider network strategies /e.g., does not implementation and evaluation of environmental
result in payment that encourages Providers modifications, using behavioral stimuli and
participating |na BCBSF network tubecome consequences bz produce socially significant
non-participating); and/or, (|»4 the improvement In human behavior, including, but
' no�|im|badto thsua�ofdinootoboona�|on
providing the specific<�owanodServices. In ' '
the case ofenOut-of-Networh Provider that measurement and functional analysis ofthe
r�|�dimne ��t���n �nvironm�nt�ndbeh�v|or
has not entered into an agreement with '
another Blue Cross and/or Blue Shield Approved Cy{micaV Trial means a phase |.
organization to provide access todiscounts phase ||. phase III, or phase |V clinical trial that
from the billed amount for the specific ie conducted in relation to the prevention,
Covered Services under the B|uaC:and (Qut' detection, or treatment of cancer or other Ufe-
of-State) Program, the Allowed Amount for Threatening Disease or Condition and meets
the specific Covered Services provided to one oy the following criteria:
you may be based upon the amount 1. The study or investigation |o approved or
provided toBCBSFby the other Blue Cross funded by one or more of the foUow|ng'
and/or Blue Shield organization vvhmnothe
'
Services were provided md the amount such o' The National Institutes ofHealth.
organization would pay non-participating b. The Centers for Disease Control and
Providers in its geographic area for such Prevention.
Services.
c. The Agency for Health Care Research
Please specifically note that, in the case ofen and Quality.
Out-of-Nobwork Provider that has not entered
into an agreement with BCB@Ftoprovide d' The Centers for Medicare and Medicaid
access twa discount from the billed amount of Se'v|000'
that Provider, the Allowed Amount for particular e. Cooperative group or center of any of
Services|o often substantially below the amount the entities described in clauses (I)
oonnmvna
22-2
0w\ cvtha �ap�dnnontof ��0�n� ��m���n '
_..__=.. ` ' ��e��mmm means any
Defense pr the Department mfVeterans following disorders as defined in the diagnostic
Affairs. categories of the International Classification of
t f`qualified non-governmental research Diseases, Ninth Edition, Clinical Modification
entity identified in the guidelines issued (ICC-9CK0). o'their equivalents in the most
bv the y�otinna| |nst�utesof Health for recently pubUshedversion ofUla��mmhoan
��^center support grants. Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders:
g. Any of the following if the conditions 1. Autistic disorder;
dasuMbedin paragraph (2) are met: '
2. Amporgor'smyndmmo;
I. The Department of Veterans Affairs.
3. Pervasive developmental disorder not
ii. The Department of Defense. otherwise specified; and
iii The Department ofEnergy. 4. Childhood Disintegrative Disorder.
Q. The study or investigation ioconducted Benefit Period means a consecutive period of
under mn investigational new drug time, specified bVBCB8F and the Group, in
application reviewed by the Food and Drug which benefits accumulate toward the
Administration
. satisfaction of Deductibles, out-mf'pooket
3' The study or investigation is a drug trial that maximums and any applicable benefit
io exempt from having such on maximums. Your Benefit Period is listed pnyour
investigational new drug application. Schedule of Benefits, and will not bo less than
18 months unless indicated aasuch.
For a study n,investigation conducted bya
Department the study or investigation must be Birth Center means a facility or institution, other
reviewed and approved through a system of than a Hospital mrAmbulatory Surgical Center,
peer review that the Secretary determines: (1)ho . which io properly licensed pursuant toChapter
be comparable tothe system of peer review of 383of the Florida Statutes, orasimilar
studies and investigations used bythe National applicable law of another state, in which births
Institutes of Health, and (Q) assures unbiased are planned to occur away from the mother's
review of the highest scientific standards by usual residence foUovvingonormal,
^qualified individuals who have no interest inthe uncomplicated, low-risk pregnancy.
outcome of the review. B7meCard(Out-of-State)Program means u
For purposes of this definition, the term "Ufe- national Blue Cross and Blue Shield Association
Threatening Disease or Condition"means any program available through Blue Cross and Blue
disease or condition from which the likelihood mf Shield of Florida, Inc. Subject to any applicable
death io probable unless the course ofthe B|ueCard(Out-of'Gtate) Program rules and
protocols, you dio�a��oruonditinn is interrupted. /
' discounts of other participating Blue Cross and/or
Artificial Insemination(Al)means amedical Blue Shield plans. See the B|ueCard(Out-of-
pnooedure in m/h|oh sperm is placed into the State) Program section for more doba||o.
' female reproductive tract by health' BUoeCand(Out~ ��0|��
care provider for the purpose of producing o �o-�x�x�� ��mammmneone
pregnancy. anetionm| Blue Cross and Blue Shield
Association program available through Blue
Cross and Blue Shield of Florida, Inc. Subject to
oonnmon,
22o
�
any applicable BlumCand(] Program other health care Provider Health Care Services
rules and protocols, you may have access to the which are rendered in order botreat the effects
B|ueCardNOut-of-State\ PPO Program discounts of, or complications arising from, the use ofhigh
of other participating Blue Cross and/or Blue dose mr intensive dose chemotherapy orhuman
Shield plans. blood precursor cells (e.g., Hospital room and
BKueCard(Omt-of-State)Traditional Program board and ancillary Services),
means a national Blue Cross and Blue Shield Calendar Year begins January 1at and ends
Association program available through Blue December 31nt
Cross and Blue Shield mf Florida, Inc. Subject to
any appUcab|aBiue(�ord(��ut-ofStmte) Program ��n�����������m��n� H��|th ���re��rvic��
rules and protocols, you ayhave access
�~the p'ovidedundo'theaupen/|eionof�phya!oi�n.
B|uo(�ard(Out'o�Gtato)Tradibmna| pnognmnn orwn �pPnophmbaprov|dort��n�dforC��ndi�o
discounts of other participating Blue Cross restoration
for the purpose of aiding in the
�nd/mr�|ue�hi�|dp|on�. reator�ionof normal hea�function |n
connection with a myocardial infarction,
BUueCerd(Out-of-State)PPO Program coronary occlusion or coronary bypass surgery.
Provider means a Provider designated aoa
B|ue(��nJ(��ut'���t�t�\ �p�� �/o�mamprovd�r Certified Nurse KN{dnniMmmeans m person who
by�hoHo/tB|um. ' io licensed pursuant toC�hepber464ofthe
Florida Statutes, ora similar applicable law of
B|oeCard(Out-of-State)Traditional Program another state, aoan advanced nurse practitioner
Provider means a Provider designated ooa and who ie certified bm practice midwifery bvthe
B|uo<�anj(��ut'o�Stata)Traditional Program ��rnerioon (�oUeQeof Nurse K8|dvviveo. '
Provider bv the Host Blue.
Certified Registered Nurse Anesthetist
Bone Marrow Transplant means human blood means a person who ioa properly licensed
precursor cells administered toe patient bz nurse who|su certified advanced registered
restore normal hematological and immunological nurse practitioner within the nurse anesthetist
functions following ablative ornon-ablative category pursuant to Chapter 4G4of the Florida
therapy with curative o[life-prolonging intent. Statutes, or a similar applicable law ofanother
Human blood precursor cells may boobtained state.
from the patient|nan outo|o0ouotnanap|ant. or
ennd|oQnna|o transplant from amod|oaUy ��y��mnUm�my�y�� �M@�mt����mmoanmany
acceptable related orunrelated donor, and may naque��qr�PPUcationfor�pV�nago�rbane��m
bodmdvodfnmrnbonemarrovx. �hmdmu|a1|og for medical care ur treatment that has not yet
blood, ora combination of bone marrow and been provided to you vvithrespect to which the
circulating blood. |f chemotherapy|manintegral application of time periods for making non-
urgent care benefit determinmdone: (1)could
tnanop|ontation. theterm "BoneyWarnovx sehouo|yjeopu»d�eyour|�eor health oryour
Transplant" includes the transplantation as well ability to regain maximum function; or in the
am the administration pf chemotherapy and the opinion ofa Physician with knowledge ofyour
chemotherapy drugs. The term "Bone Marrow Condition, would subject you 0o severe pain that
Transplant" also includes any Services or cannot be adequately managed without the
supplies relating bo any treatment ortherapy proposed Services being rendered.
involving the use mf high dose nr intensive dose Coinsurance means your share of health care
chemotherapy and human blood precursor cells expenses for Covered Services. After your
and includes any and all Hoopita|. Physician or Deductible requirement is met, a percentage of
mmnmono
22-4
the Allowed Amount will be paid for Covered paid to a health care Provider u �t��� '
Smndcem, me�m�mdin the Schedule mfBeneh n
�m. �qw�re� �� ioensrerendared^ 'by that Prov'dex
The percentage you are responsible for kayour Cost Share may include, but|m -'limited to
'
Coinsurance.
Coinsurance, Cmosynnent. Deductible and/or Per
Concurrent Care Decision means adecision Admission Deductible (PAD) amounts.
hyueto deny, reduce, or terminate coverage, Applicable Coot Share amounts are identified in
benefits, or payment(in whole orin part)with your Schedule ofBenefits.
respect toa course of treatment tobaprovided Covered Dependent means anEligible
over a period of time, nra specific number pf Dependent who meets and continues to meet all
tneotmmnb», if we had previously approved or applicable eligibilitynoqu|mamonbs and who is
outhohzedinwdt|ng coverage, beno�ta. o, enrolled, and actually covered, under the Group
payment for that course of treatment o,number Health Plan other than aoa Covered Plan
oYtreatments.
Participant(See the "Eligibility Requirements for
Ao defined herein, a Concurrent Care Decision Dmpendent(n)"subsection of the"Eligibility for
shall not include any decision bz deny, reduce, Coverage"section).
or terminate coverage, benefits, mrpayment Covered Person means a Covered Plan
under the personal case management Program Participant oro Covered Oopendent
aodeanhbodin the"B|uaphntFor Hoabh '
Programs"section of this Benefit Booklet. Covered Plan Participant means onEligible
Employee or other individual who meets and
Condition means a disease iUn��� ailment,
. ' ' continues to meet all oppUoob|o eligibility
injury, orpregnancy. requirements and who ioenrolled, and actually
Convenient Care Center means aproperly covered, under this Benefit Booklet other than
licensed ambulatory center that: 1)treats a amo Covered Dependent.
limited number of common, low-intensity Covered Services means those Health Care
illnesses when ready access bo the patient's Services which meet the criteria listed inthe
primary physician io not possible; 2)shares 'What|mCpvemad?paection
clinical information about the�oatmentvv|Uh the
^
patient's primary physician; 3) ia usually housed Custodial on Custodial Care means care that
in a retail business; and 4) is staffed by at least serves to assist an individual in the activities of
one master's level nurse (ARNp)who operates daily living, such ao assistance|nwalking,
under set ofclinical protocols that strictly getting in and out of bed, bsdhing, dressing,
circumscribe the conditions the ARMp can treat. feeding, and using the toilet, preparation of
Although no physician |e present otthe special diets, and supervision of medication that
Convenient Care Center, medical oversight|a usually can be self-administered. Custodial
based onawritten collaborative agreement Care essentially io personal care that does not
between a supervising physician and the ARNp. require the continuing attention wftrained
medical or paramedical personnel. In
������m�mm�mo�nath�doUaramount
e��abUohedoP|�|yby�(���� and Monroe deterrniningm/hedhera person iareceiving
��ountyB��{�C�vvh|oh |o required bobe paid toa (�ugtodia| C�eno' non�ido�d|oniogivonto�h�
frequency, intensity and level of care and
health care Provider by you ot the time certain
medical supervision required and furn|ahed A(�ovenadSen/inaaanenondoredbythotprovidor' detorrninodiomthat care received ia(�ustodi'| io
Cost Share means the dollar orpercentage not based on the patient's diagnosis, type of
amount established solely byus, vvh|oh must be
Demnmono
22-5
Condition, degree of functional limitation, or individual in the absence of a Condition; and
rehabilitation potential. 5) is appropriate for use in the home.
Deductible means the amount of charges, up to Durable Medical Equipment Provider means a
the Allowed Amount, for Covered Services that person or entity that is properly licensed, if
are your responsibility. The term, Deductible, applicable, under Florida law(or a similar
does not include any amounts you are applicable law of another state)to provide home
responsible for in excess of the Allowed Amount, medical equipment, oxygen therapy services, or
or any Coinsurance/Copay amounts, if dialysis supplies in the patient's home under a
applicable. Physician's prescription.
Detoxification means a process whereby an Effective Date means, with respect to
alcohol or drug intoxicated, or alcohol or drug individuals covered under this Benefit Booklet,
dependent, individual is assisted through the 12:01 a.m. on the date Monroe County BOCC
period of time necessary to eliminate, by specifies that the coverage will commence as
metabolic or other means, the intoxicating further described in the"Enrollment and
alcohol or drug, alcohol or drug dependent Effective Date of Coverage"section of this
factors or alcohol in combination with drugs as Benefit Booklet.
determined by a licensed Physician or
Psychologist, while keeping the physiological Eligible Dependent means an individual who
risk to the individual at a minimum. meets and continues to meet all of the eligibility
requirements described in the Eligibility
Diabetes Educator means a person who is Requirements for Dependent(s) subsection of
properly certified pursuant to Florida law, or a the Eligibility for Coverage section in this Benefit
similar applicable law of another state,to Booklet, and is eligible to enroll as a Covered
supervise diabetes outpatient self-management Dependent.
training and educational services.
Eligible Employee means an active employee
Dialysis Center means an outpatient facility or retiree who meets and continues to meet all
certified by the Centers for Medicare and of the eligibility requirements described in the
Medicaid Services (CMMS) and the Florida Eligibility Requirements for Covered Plan
Agency for Health Care Administration (or a Participant subsection of the Eligibility for
similar regulatory agency of another state)to Coverage section in the Benefit Booklet and is
provide hemodialysis and peritoneal dialysis eligible to enroll as a Covered Plan Participant.
services and support. Any individual who is an Eligible Employee is not
Dietitian means a person who is properly
a Covered Plan Participant until such individual licensed pursuant to Florida law or a similar has actually enrolled with, and been accepted
applicable law of another state to provide for coverage as a Covered Plan Participant by nutrition counseling for diabetes outpatient self-
Monroe County BOCC.
management services. Emergency Medical Condition means a
Durable Medical Equipment means equipment medical or psychiatric Condition or an injury
furnished by a supplier or a Home Health manifesting itself by acute symptoms of
Agency that: 1) can withstand repeated use;
sufficient severity(including severe pain) such
that a prudent layperson, who possesses an
2) is primarily and customarily used to serve a medical purpose; 3) not for comfort or average knowledge of health and medicine,convenience; 4) generally is not useful to an could reasonably expect the absence of
immediate medical attention to result in a
Deflnitlons
22-6
condition described in clause 0. (ii). or(III) of 2. such evaluation, -, �o� � --~'*� or
Section #Q n18@7&nr1\ mfthe8o�a Security C v�� dev�ekep �' punmuant to a n
Emergency Services means, with respect to an protocol which describes as among its
Emergency Medical Condition: objectives the following: determinations of
safety, efficacy, or efficacy|n comparison to
1. a medical screening examination (as the standard evaluation, treadment, therapy,
required under Section 1BG7of the Social or device;
or
SaourbyAot)thodiowith|nthanapabi|itvof 8. such evaluation,on treatment,therapy, orthoemerQonnydopedmentofaHoopita|. device is delivered pr should be deliver
ed
inu|udinQ ancillary Services routinely subject bothe approval and supervision of
available tothe emergency department to
a��|uatoeuuhEmaqJmnoyK8�dina| an institutional revam/board or other entity
eo required and defined b�federal
Condition; ^
. regulations; or
2. within the capabilities of the staff and 4` credible scientific evidence shows that such
facilities available o1 the hospital, such evaluation, treatment, therapy, or device~is
further medical examination and tnmednnent the subject ofan ongoing Phase | or||
ao are required under Section 1867ofsuch clinical investigation, or the experimental or
Act to Stabilize the patient. research arm cfa Phase III clinical
Endorsement means on amendment tothe investigation, or under study todetermine:
Group Health Plan or this Booklet. maximum tolerated dooage(s). toxicity,
safety, efficacy, or efficacy aocompared
Enrollment Date means the date mfenrollment with the standard means for treatment or
of the individual under the Group Health Plan or, diagnosis of the Condition in question; or
if earlier,the first dav nftheVV�dim� �ehmd��
such enrollment, ' 5' credible scientific evidence shows that the
consensus of opinion among experts is that
Enrollment Forms means those forms, further studies, neeoanoh, or clinical
electronic (where available) or paper, which are investigations are necessary to d 'rrn1na:
used to maintain accurate enrollment files under maximum tolerated doeage(s), toxicity,
this Benefit Booklet. safety, efficacy, or efficacy aacompared
Experimental on Investigational means any with the standard means for treatment mr
evaluation, treatment, therapy, or device which diagnosis of the Condition in question; or
involves the application, administration or use, of M' credible scientific evidence shows that such
procedures, techniques, equipment, supplies, evaluation, treatment, therapy, or device has
products, remedies, vaccines, biological not been proven safe and effective for
products, drugs, pharmaceuticals, or chemical treatment cf the Condition |n question, as
compounds if, aa determined solely byBCBSF: evidenced in the most recently published
K8odioe| Literature in the United Stotea
1. such evaluation, treatment,therapy, or Canada, or<�rsed Britain, using gono—`~~|Yy
device cannot be |av�uU marketed ance�edscientific, medical, orpuWi~— health
approval of the United States Food and methodologies or statistical practices; r
Drug Administration or the Florida ~
Department cf Health and approval for 7' there iono consensus among practicing
marketing has not, |n fact, been given edthe Physicians that the treatment, therapy, or
time such ie furnished to you; or device iosafe and effective for the Condition
in question; or
Demnmono
22-7
1
8. such evaluation, treatment,therapy, or also rely on the predominant opinion among
device is not the standard treatment, experts, as expressed in the published
therapy, or device utilized by practicing authoritative literature,that usage of a
Physicians in treating other patients with the particular evaluation,treatment,therapy, or
same or similar Condition. device should be substantially confined to
"Credible scientific evidence"shall mean (as research settings or that further studies are
determined by BCBSF): necessary in order to define safety,toxicity,
effectiveness, or effectiveness compared
1. records maintained by Physicians or with standard alternatives.
Hospitals rendering care or treatment to you
or other patients with the same or similar FDA means the United States Food and Drug
Condition; Administration.
2. reports, articles, or written assessments in Foster Child means a person who is placed in
authoritative medical and scientific literature your residence and care under the Foster Care
published in the United States, Canada, or Program by the Florida Department of Health &
Great Britain; Rehabilitative Services in compliance with
3. published reports, articles, or other literature Florida Statutes or by a similar regulatory
of the United States Department of Health agency of another state in compliance with that
and Human Services or the United States state's applicable laws.
Public Health Service, including any of the Gamete Intrafallopian Transfer(GIFT)means
National Institutes of Health, or the United the direct transfer of a mixture of sperm and
States Office of Technology Assessment; eggs into the fallopian tube by a qualified health
4. the written protocol or protocols relied upon care provider. Fertilization takes place inside
by the treating Physician or institution or the the tube.
protocols of another Physician or institution Generally Accepted Standards of Medical
studying substantially the same evaluation, Practice means standards that are based on
treatment, therapy, or device; credible scientific evidence published in peer-
5. the written informed consent used by the reviewed medical literature generally recognized
treating Physician or institution or by another by the relevant medical community, Physician
Physician or institution studying substantially Specialty Society recommendations, and the
the same evaluation,treatment, therapy, or views of Physicians practicing in relevant clinical
device; or areas and any other relevant factors.
6. the records(including any reports) of any Gestational Surrogate means a woman,
institutional review board of any institution regardless of age,who contracts, orally or in
which has reviewed the evaluation, writing, to become pregnant by means of
treatment, therapy, or device for the assisted reproductive technology without the use
Condition in question. of an egg from her body.
Note: Health Care Services which are Gestational Surrogacy Contract or
determined by BCBSF to be Experimental or Arrangement means an oral or written
Investigational are excluded(see the"What agreement, regardless of the state or jurisdiction
Is Not Covered?"section). In determining where executed, between the Gestational
whether a Health Care Service is Surrogate and the intended parent or parents.
Experimental or Investigational, BCBSF may
DeBnlOons
22-8
Group means the employer, labor union, trust, supportive services to terminally ill persons and
association, partnership, or corporation, their families.
department, other organization or entity through Hospital means a facility properly licensed
which coverage and benefits under this Benefit
Booklet are made available to you, and through pursuant to Chapter 395 of the Florida Statutes,
which you and your Covered Dependents or a similar applicable law of another state, that:
become entitled to coverage and benefits for the offers services which are more Intensive than
Covered Services described herein. those required for room, board, personal
services and general nursing care; offers
Group Health Plan or Group Plan means the facilities and beds for use beyond 24 hours; and
plan established and maintained by Monroe regularly makes available at least clinical
County BOCC for the provision of health care laboratory services, diagnostic x-ray services
coverage and benefits to the individuals covered and treatment facilities for surgery or obstetrical
under this Benefit Booklet. care or other definitive medical treatment of
Health Care Services or Services includes similar extent,
treatments,therapies, devices, procedures, The term Hospital does not include: an
techniques, equipment, supplies, products, Ambulatory Surgical Center; a Skilled Nursing
remedies, vaccines, biological products, drugs, Facility; a stand-alone Birthing Center; a
pharmaceuticals, chemical compounds, and Psychiatric Facility; a Substance Abuse Facility;
other services rendered or supplied, by or at the a convalescent, rest or nursing home; or a
direction of, Providers. facility which primarily provides Custodial,
Home Health Agency means a properly educational, or Rehabilitative Therapies.
licensed agency or organization which provides Note: If services specifically for the
health services in the home pursuant to Chapter treatment of a physical disability are
400 of the Florida Statutes, or a similar provided In a licensed Hospital which Is
applicable law of another state. accredited by the Joint Commission on the
Home Health Care or Home Health Care Accreditation of Health Care Organizations,
Services means Physician-directed the American Osteopathic Association, or
professional, technical and related medical and the Commission on the Accreditation of
personal care Services provided on an Rehabilitative Facilities, payment for these
intermittent or part-time basis directly by(or services will not be denied solely because
indirectly through)a Home Health Agency in such Hospital lacks major surgical facilities
your home or residence. For purposes of this and Is primarily of a rehabilitative nature.
definition, a Hospital, Skilled Nursing Facility, Recognition of these facilities does not
nursing home or other facility will not be expand the scope of Covered Services. It
considered an individual's home or residence. only expands the setting where Covered
Services can be performed for coverage
Hospice means a public agency or private purposes.
organization which is duly licensed by the State Identification(ID)Card means the card(s)
of Florida under applicable law, or a similar issued to Covered Plan Participants under the
applicable law of another state,to provide BlueOptions Group Health Plan. The card is not
hospice services. In addition, such licensed entity must be principally engaged in providing transferable to another person. Possession of
such card in no way guarantees that a particular
pain relief, symptom management, and individual is eligible for, or covered under, this
Benefit Booklet.
Definiflons
22-9
Independent Clinical Laboratory means a Florida who or which, at the time Health Care
laboratory properly licensed pursuant to Chapter Services were rendered to you, participated as a
483 of the Florida Statutes, or a similar BlueCard (Out-of-State) PPO Program Provider
applicable law of another state,where under the Blue Cross Blue Shield Association's
examinations are performed on materials or BlueCard (Out-of-State) Program.
specimens taken from the human body to Intensive Outpatient Treatment means
provide information or materials used in the
diagnosis, prevention, or treatment of a treatment in which an individual receives at least
Condition. 3 clinical hours of institutional care per day(24-
hour period)for at least 3 days a week and
Independent Diagnostic Testing Facility returns home or is not treated as an inpatient
means a facility, independent of a Hospital or during the remainder of that 24-hour period. A
Physician's office,which is a fixed location, a Hospital shall not be considered a "homen for
mobile entity, or an individual non-Physician purposes of this definition.
practitioner where diagnostic tests are
performed by a licensed Physician or by In Vitro Fertilization(IVF)means a process in
licensed, certified non-Physician personnel which an egg and sperm are combined in a
under appropriate Physician supervision. An laboratory dish to facilitate fertilization. If
Independent Diagnostic Testing Facility must be fertilized, the resulting embryo is transferred to
appropriately registered with the Agency for the woman's uterus.
Health Care Administration and must comply Licensed Practical Nurse means a person
with all applicable Florida law or laws of the properly licensed to practice practical nursing
State in which it operates. Further, such an pursuant to Chapter 464 of the Florida Statues,
entity must meet BCBSF's criteria for eligibility or a similar applicable law of another state.
as an Independent Diagnostic Testing Facility.
In-Network means, when used in reference to Massage Therapist means a person properly
Covered Services, the level of benefits payable licensed to practice Massage, pursuant to
Chapter 480 of the Florida Statutes, or a similar
to an In-Network Provider as designated on the
Schedule of Benefits under the heading 1n- applicable law of another state.
Network". Otherwise, In-Network means, when Massage or Massage Therapy means the
used in reference to a Provider, that, at the time manipulation of superficial tissues of the human
Covered Services are rendered,the Provider is body using the hand,foot, arm, or elbow. For
an In-Network Provider under the terms of this purposes of this Benefit Booklet, the term
Booklet. Massage or Massage Therapy does not include
In-Network Provider means any health care the application or use of the following or similar
Provider who, at the time Covered Services techniques or items for the purpose of aiding in
were rendered to you, was under contract with the manipulation of superficial tissues: hot or
BCBSF to participate in BCBSF's NetworkBlue cold packs; hydrotherapy; colonic irrigation;
and included in the panel of providers thermal therapy; chemical or herbal
designated by BCBSF as "In-Network"for your preparations; paraffin baths; infrared light;
specific plan. (Please refer to your Schedule of ultraviolet light; Hubbard tank; or contrast baths.
Benefits). For payment purposes under this Mastectomy means the removal of all or part of
Benefit Booklet only, the term In-Network the breast for Medically Necessary reasons as
Provider also refers, when applicable, to any determined by a Physician.
health care Provider located outside the state of
Definiflons
22-10
Medical Literature means scientific studies a. the Allowed Amount for Service at the
published in a United States peer-reviewed location for the delivery of the Service
national professional journal. versus an alternate setting;
Medical Pharmacy Physician-administered b. the amount we have to pay to the proposed
Prescription Drugs which are rendered in a particular Provider versus the Allowed
Physician's office. Amount for a Service by another Provider
Medically Necessary or Medical Necessity including Providers of the same and/or
means that, with respect to a Health Care different licensure and/or specialty; and/or,
Service, a Provider, exercising prudent clinical c. an analysis of the therapeutic and/or
judgment, provided, or is proposing or diagnostic outcomes of an alternate
recommending to provide the Health Care treatment versus the recommended or
Service to you for the purpose of preventing, performed procedure including a
evaluating, diagnosing or treating an illness, comparison to no treatment. Any such
injury, disease or its symptoms, and that the analysis may include the short and/or long-
Health Care Service was/is: term health outcomes of the recommended
or performed treatment versus alternate
1. in accordance with Generally Accepted treatments including an analysis of such
Standards of Medical Practice; outcomes as the ability of the proposed
2. clinically appropriate, in terms of type, procedure to treat comorbidities,time todisease recurrence,the likelihood of
frequency, extent, site of Service, duration, additional Services in the future, etc.
and considered effective for your illness,
Note: The distance you have to travel to receive
injury, or disease or symptoms; a Health Care Service, time off from work,
3. not primarily for your convenience, your overall recovery time, etc. are not factors that we
family's convenience, your caregiver's are required to consider when evaluating
convenience or that of your Physician or whether or not a Health Care Service is not
other health care Provider, and more costly than an alternative Service or
4. not more costly than the same or similar sequence of Services.
Service provided by a different Provider, by Reviews we perform of Medical Necessity may
way of a different method of administration, be based on comparative effectiveness
an alternative location (e.g., office vs. research, where available, or on evidence
inpatient), and/or an alternative Service or showing lack of superiority of a particular
Service or lack of difference in outcomes with
sequence of Services at least as likely to respect to a particular Service. In performing
produce equivalent therapeutic or diagnostic Medical Necessity reviews, we may take into
results as to the diagnosis or treatment of consideration and use cost data which may be
your illness, injury, disease or symptoms. proprietary.
When determining whether a Service is not It is important to remember that any review of
more costly than the same or similar Service as Medical Necessity by us is solely for the purpose
referenced above, we may, but are not required of determining coverage or benefits under this
to,take into consideration various factors Booklet and not for the purpose of
including, but not limited to,the following: recommending or providing medical care. In this
respect, we may review specific medical facts or
information pertaining to you. Any such review,
DeflnlOons "
however, is strictly for the purpose of regardless of the underlying cause, or effect, of
determining, among other things, whether a the disorder.
Service provided or proposed meets the Midwife means a person properly licensed to
definition of Medical Necessity in this Booklet as practice midwife
determined by us. In applying the definition of p midwifery pursuant to Chapter 467 of
the Florida Statutes, or a similar applicable law
Medical Necessity in this Booklet, we may apply
our coverage and payment guidelines then in of another state.
effect. You are free to obtain a Service even if NetworkBlue means, or refers to,the preferred
we deny coverage because the Service is not provider network established and so designated
Medically Necessary; however, you will be solely by BCBSF which is available to individuals
responsible for paying for the Service. covered under this Benefit Booklet. Please note
Medicare means the federal health insurance that BCBSF's Preferred Patient Care (PPG)
provided under Title XVIII of the Social Security preferred provider network is not available to
Act and all amendments thereto. individuals covered under this Benefit Booklet.
Medication Guide for the purpose of this Occupational Therapist means a person
Benefit Booklet means the guide then in effect properly licensed to practice Occupational
issued by us where you may find information Therapy pursuant to Chapter 468 of the Florida
about Specialty Drugs, Prescription Drugs that Statutes, or a similar applicable law of another
require prior coverage authorization and Self- state.
Administered Prescription Drugs that may be Occupational Therapy means a treatment that
covered under this plan. follows an illness or injury and is designed to
Note: The Medication Guide is subject to help a patient learn to use a newly restored or
change at any time. Please refer to our website previously impaired function.
at www.floridablue.com for the most current Orthotic Device means any rigid or semi-rigid
guide or you may call the customer service device needed to support a weak or deformed
phone number on your Identification Card for body part or restrict or eliminate body
current information. movement.
Mental Health Professional means a person Out-of-Network means, when used in reference
properly licensed to provide mental health to Covered Services,the level of benefits
Services, pursuant to Chapter 491 of the Florida payable to an Out-of-Network Provider as
Statutes, or a similar applicable law of another designated on the Schedule of Benefits under
state. This professional may be a clinical social the heading"Out-of-Network". Otherwise, Out-
worker, mental health counselor or marriage and of-Network means, when used in reference to a
family therapist. A Mental Health Professional Provider, that, at the time Covered Services are
does not include members of any religious rendered, the Provider is not an In-Network
denomination who provide counseling services. Provider under the terms of this Booklet.
Mental and Nervous Disorder means any Out-of-Network Provider means a Provider
disorder listed In the diagnostic categories of the who, at the time Health Care Services were
International Classification of Disease (ICD-9 rendered:
CM or ICD 10 CM), or their equivalents in the 1. did not have a contract with us to participate
most recently published version of the American in NetworkBlue but was participating in our
Psychiatric Association's Diagnostic and Traditional Program; or
Statistical Manual of Mental Disorders,
Deflnitlons
22-12
2. did not have a contract with a Host Blue to programs featuring multidisciplinary Services
participate in its local PPO Program for directed toward helping those with chronic pain
purposes of the BlueCard (Out-of-State) to reduce or limit their pain.
PPO Program but was participating, for Partial Hospitalization means treatment in
purposes of the BlueCard (Out-of-State) which an individual receives at least 6 clinical
Program, as a BlueCard (Out-of-State)Traditional Program Provider; or hours of institutional care per day(24-hour
3. did have a contract to participate in period)for at least 5 days per week and returns
NetworkBlue but was not included in the home or is not treated as an inpatient during the
remainder of that 24-hour period. A Hospital
panel of Providers designated by us to be
In-Network for your Plan; or shall not be considered a"home"for purposes of
4. did not have a contract with us to participate this definition.
in NetworkBlue or our Traditional Program; Physical Therapy means the treatment of
or disease or injury by physical or mechanical
5. did not have a contract with a Host Blue to means as defined in Chapter 486 of the Florida
participate for purposes of the BlueCard Statutes or a similar applicable law of another
(Out-of-State) Program as a BlueCard (Out- state. Such therapy may include traction, active
of State)Traditional Program Provider. or passive exercises, or heat therapy.
Outpatient Rehabilitation Facility means an Physical Therapist means a person properly
entity which renders, through providers properly licensed to practice Physical Therapy pursuant
licensed pursuant to Florida law or the similar to Chapter 486 of the Florida Statutes, or a
law or laws of another state: outpatient physical similar applicable law of another state.
therapy; outpatient speech therapy; outpatient Physician means any individual who is properly
occupational therapy; outpatient cardiac licensed by the state of Florida, or a similar
rehabilitation therapy; and outpatient Massage applicable law of another state, as a Doctor of
for the primary purpose of restoring or improving Medicine(M.D.), Doctor of Osteopathy(D.O.),
a bodily function impaired or eliminated by a Doctor of Podiatry(D.P.M.), Doctor of
Condition. Further, such an entity must meet Chiropractic (D.C.), Doctor of Dental Surgery or
BCBSF's criteria for eligibility as an Outpatient Dental Medicine (D.D.S. or D.M.D.), or Doctor of
Rehabilitation Facility. The term Outpatient Optometry(O.D.).
Rehabilitation Facility, as used herein, shall not
Include any Hospital Including a general acute Physician Assistant means a person properly
care Hospital, or any separately organized unit licensed pursuant to Chapter 458 of the Florida
of a Hospital, which provides comprehensive Statutes, or a similar applicable law of another
medical rehabilitation inpatient services, or state.
rehabilitation outpatient services, including, but Physician Specialty Society means a United
not limited to, a Class III "specialty rehabilitation States medical specialty society that represents
hospital"described in Chapter 59A, Florida diplomates certified by a board recognized by
Administrative Code or the similar law or laws of the American Board of Medical Specialties.
another state.
Post-Service Claim means any paper or
Pain Management includes, but is not limited electronic request or application for coverage,
to, Services for pain assessment, medication, benefits, or payment for a Service actually
physical therapy, biofeedback, and/or provided to you (not just proposed or
counseling. Pain rehabilitation programs are recommended)that is received by us on a
Definiflons
22-13
properly completed claim form or electronic functions of a permanently inoperative or
format acceptable to us in accordance with the malfunctioning body part or organ.
provisions of this section.
Provider means any facility, person or entity
Pre-Service Claim means any request or recognized for payment by BCBSF under this
application for coverage or benefits for a Service Booklet.
that has not yet been provided to you and with
respect to which the terms of the Benefit Booklet Psychiatric Facility means a facility properly
condition payment for the Service (in whole or in licensed under Florida law, or a similar
part) on approval by us of coverage or benefits applicable law of another state,to provide for the
for the Service before you receive it. A Pre- care and treatment of Mental and Nervous
Service Claim may be a Claim Involving Urgent Disorders. For purposes of this Booklet, a
Care. As defined herein, a Pre-Service Claim Psychiatric Facility is not a Hospital or a
shall not include a request for a decision or Substance Abuse Facility, as defined herein.
opinion by us regarding coverage, benefits, or Psychologist means a person properly licensed
payment for a Service that has not actually been to practice psychology pursuant to Chapter 490
rendered to you if the terms of the Benefit of the Florida Statutes, or a similar applicable
Booklet do not require (or condition payment law of another state.
upon) approval by us of coverage or benefits for
the Service before it is received. Registered Nurse means a person properly
licensed to practice professional nursing
Prescription Drug means any medicinal pursuant to Chapter 464 of the Florida Statutes,
substance, remedy, vaccine, biological product, or a similar applicable law of another state.
drug, pharmaceutical or chemical compound
which can only be dispensed with a Prescription Registered Nurse First Assistant(RNFA)
and/or which is required by state law to bear the means a person properly licensed to perform
following statement or similar statement on the surgical first assisting services pursuant to
label: "Caution: Federal law prohibits Chapter 464 of the Florida Statutes or a similar
dispensing without a Prescription". applicable law of another state.
Prior/Concurrent Coverage Affidavit means Rehabilitation Services means Services for the
the form that an Eligible Employee or Eligible purpose of restoring function lost due to illness,
Dependent can submit to BCBSF as proof of the injury or surgical procedures including but not
amount of time the Eligible Employee was limited to cardiac rehabilitation, pulmonary
covered under Creditable Coverage. rehabilitation, Occupational Therapy, Speech
Therapy, Physical Therapy and Massage
Prosthetist/Orthotist means a person or entity Therapy.
that is properly licensed, if applicable, under
Florida law, or a similar applicable law of Rehabilitative Therapies means therapies the
another state,to provide services consisting of primary purpose of which is to restore or
the design and fabrication of medical devices improve bodily or mental functions impaired or
such as braces, splints, and artificial limbs eliminated by a Condition, and include, but are
prescribed by a Physician. not limited to, Physical Therapy, Speech
Therapy, Pain Management, pulmonary therapy
Prosthetic Device means a device which or Cardiac Therapy.
replaces all or part of a body part or an internal
body organ or replaces all or part of the Self-Administered Prescription Drug means
an FDA-approved Prescription Drug that you
Deflniflons
22-14
may administer to yourself, oa recommended by Stabilize shall have the same meaning with
a Physician. regard to Emergency Services am the term is
Skilled Nursymg FacUl�mm�s� i��onor d�n� inS�� 18���eB�� S�ur�
'part thereof which meets BCBSF'mch Act.
eligibility asaSkilled Nursing Facility and which: Speech Therapist means a person properly
1\ |a licensed as a Skilled Nursing Facility bythe licensed to practice Speech Therapy pursuant to
state of Florida ora similar applicable law of Chapter 4G8of the Florida Statutes, orasimilar
another state; and Q)is onurgdibad as a Skilled applicable law of another state.
Nursing Facility b*the Joint Commission on
Accreditation mf Healthcare Organizations or Standard Reference Compendium means:
recognized aaa Skilled Nursing Facility bythe 1)the United States Pharmacopoeia Drug
Secretary of Health and Human Services ofthe Information; 2)the American Medical
United States under Medicare, unless such Association Drug Evaluation; or3)the American
accreditation or recognition requirement has Hospital Formulary Service Hospital Drug
been waived bvBCBSF. Information.
Sound Natural Teeth means teeth that are Substance Abuse Facility means afanUbv
whole or properly restored (restoration with properly licensed under Florida law, orasimilar
ame/gama, noa|n or composite only); are without aPP|ioab|o law of another state,to provide
impairment, periodontal, or other conditions; and necessary care and treatment for Substance
are not in need of Services provided for any Dependency. For the purposes nf this Booklet a
reason other than an Accidental Dental Injury. Substance Abuse Facility io not a Hospital ora
Teeth previously restored with o crown, inlay, Psychiatric Facility, aa defined herein.
on|eV or porcelain restoration, or treated with Substance Dependency means aCondition
endodont|os �r� not�oundNetuma|���th
. ' where penaon'o alcohol or drug use injures his
Specialty Drug means anFDA-approved o'her health; interferes with his or her social o'
Prescription Drug that has been designated, economic functioning; mr causes the individual to
solely byus, aooSpecialty Drug due bzspecial |ooa self-control.
hendUng, storage,training, distribution Traditional Program means, or refers bm
requirements and/or manogenmantofthonap� B<�BSF'o provider contracting programs~`mUed
Specialty Drugs may be Provider administered Payment for Physician Services (PPS\—�^d
ormeN�sdmin|mteredand are identified with a Payment for Hospital Services � `H�1 ' r
special symbol in the Medication Guide. `' '' For purposes th|aBenefit Booklet, the term
Specialty Pharmacy means m Pharmacy that Traditional Program also refers, when
has signed Participating Pharmacy Provider applicable, to the traditional Provider contracting
Agreement with unto provide specific programs of other Blue Cross and/or Blue Shield
Prescription Drug products, ao determined by organizations os designated under the Blue
us. In-Network Specialty Pharmacies are listed Cross and Blue Shield Association's B|ueCand
in the Medication Guide. pnoQnsm.
Speech Therapy means the treatment of Traditional Program Providers means, or
speech and language disorders bya Speech refers to,those health care Providers who are
Therapist including language assessment and not Nebwpd«B|ue Providers, but who, or which, at
language restorative therapy services. the time you received Services from them were
participating in the Traditional Program. For
Demomvnv
22-10
purposes of payment under this Benefit Booklet to the fallopian tube at the pronuclear stage
only, the term Traditional Program Provider also (before cell division takes place). The eggs are
refers, when applicable, to any health care retrieved and fertilized on one day and the
Provider located outside the state of Florida who zygote is transferred the following day.
or which, at the time Health Care Services were
rendered to you, participated as a BlueCard
Traditional Provider under the Blue Cross and
Blue Shield Association's BlueCard Program.
Traditional providers are considered out of
network for benefit calculation purposes;
however, does not balance bill the member.
Urgent Care Center means a facility properly
licensed that: 1) is available to provide Services
to patients at least 60 hours per week with at
least twenty-five (25)of those available hours
after 5:00 p.m. on weekdays or on Saturday or
Sunday; 2)posts instructions for individuals
seeking Health Care Services, in a conspicuous
public place, as to where to obtain such
Services when the Urgent Care Center is
closed; 3)employs or contracts with at least one
or more Board Certified or Board Eligible
Physicians and Registered Nurses (RNs)who
are physically present during all hours of
operation. Physicians, RNs, and other medical
professional staff must have appropriate training
and skills for the care of adults and children; and
4) maintains and operates basic diagnostic
radiology and laboratory equipment in
compliance with applicable state and/or federal
laws and regulations.
For purposes of this Benefit Booklet, an Urgent
Care Center is not a Hospital, Psychiatric
Facility, Substance Abuse Facility, Skilled
Nursing Facility or Outpatient Rehabilitation
Facility.
Waiting Period means the length of time
established by Monroe County BOCC which
must be met by an individual before that
individual becomes eligible for coverage under
this Benefit Booklet.
Zygote Intrafalloplan Transfer(ZIF7) means a
process in which an egg is fertilized in the
laboratory and the resulting zygote is transferred
Deffniflons
22-16
Qualified Medical Child Support Orders Disclaimer
Qualified Medical Child Support Orders-
The Plan will provide benefits as required by any
Qualified Medical Child Support Order (MCSO). A MCSO can be either:1) A Qualified Medical Child
Support Order (MCSO) that satisfies the requirements of Section 609(a) of ERISA;or 2) A National
Medical Support Notice (NMSN)that satisfies the requirements of Section 1908 of the Social Security Act.
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 Covered
Employee/Retiree will need to provide any reasonable information or assistance to the Monroe County
Group Health Plan Administrator(Benefits Office) in connection with the MCSO.
Disclalmer
Domestic Partner Coverage Endorsement
This Endorsement is to be attached to and made S. the Covered Employee has completed and
a part of the current Benefit Booklet and any submitted any required forms to the Group
Endorsements attached thereto. The Benefit and the Group has determined the Domestic
Booklet is amended as described below to Partnership eligibility requirements have
provide coverage for a Domestic Partner of a been met.
Covered Employee(employee only) and, if
applicable, the dependent child(ren) of a Eligibility for Coverage
Domestic Partner.
Domestic Partner and Dependent Children)
Glossary of Terms of Domestic Partners Eligibility
Domestic Partner imeens a person of the same The following individuals are eligible to apply for
or opposite sex with whom the Covered coverage under the Benefit Booklet:
Employee(employee only)has established a
1, the Covered Employee's (employee only)
Domestic Partnership. present Domestic Partner;
Domestic Partnership means a relationship 2. the Covered Domestic Partner's dependent
between a Covered (Employee(employee only)
and one other person of the same or opposite child(ren),who is under the limiting age,who
sex who meet at a minimum, the following meets all of the fallowing eligibility
eligibility requirements: requirements, and the eligibility requirements
1. both /individuals are each other's sole under the Benefit Booklet:
Domestic Partner and intend to remain so a. resides regularly with the Covered
indefinitely; Employee and the Domestic Partner, or
2. individuals are not related by blood to a the Domestic Partner is required to
degree of closeness (e.g., siblings)that provide coverage for the child(ren)by
would prohibit legal marriage in the state in court order; or
which they legally reside; b, the child(ren)qualifies as the Domestic
3. both individuals are unmarried, at least 18 Partner's dependent(s) for tax purposes
years of age, and are mentally competent to under the federal guidelines; and
consent to the Domestic Partnership; c. the child(ren)meets and continues to
4. both individuals are financially meet the eligibility requirements as
interdependent and have resided together outlined in the Eligibility Requirements
continuously in the same residence for at for Dependent(s)subsection of the
least six months prior to applying for Benefit Booklet.
coverage under the Benefit Booklet and Domestic Partner Enrollment Forms/
intend to continue to reside together
indefinitely; Electing Coverage
5. the Covered Employee has submitted to the When an Eligible Employee is making
Group acceptable proof of evidence of application for coverage for his/her Domestic
common residence and joint financial Partner and the Domestic Partner's dependent
responsibility; and child(ren), the Eligible Employee must complete
ASO Dom Pert with Dep END
Plan 03559
1
and submit through the Group any required rules to apply for continuation of coverage under
Enrollment Forms. When an Eligible Employee the MCBCC Group Health Plan.
is electing coverage for his/her self and his/her Miscellaneous
Domestic Partner, and Employee/Spouse
Coverage is available under the Group's The term Eligible Dependent is modified to also
program, Employee/Spouse Coverage is include the reference to Domestic Partner when
redefined as Employee/Domestic Partner spouse is referenced.
Coverage.
Domestic Partner Enrollment Periods This Endorsement shall not extend, vary, alter,
replace, or waive any of the provisions, benefits,
An Eligible Employee may make application for exclusions, limitations, or conditions contained in
an eligible Domestic Partner and the Domestic the Benefit Booklet, other than as specifically
Partner's dependent children)during the stated in the provisions contained in this
following enrollment periods and as outlined in Endorsement. In the event of any
the Benefit Booklet: inconsistencies between the provisions
1. employee's Initial Enrollment Period; contained in this Endorsement and the
2. Annual Open Enrollment Period; provisions contained in the Benefit Booklet, the
provisions contained in this Endorsement shall
3. Special Enrollment Period; or
control to the extent necessary to effectuate the
4. within the 30-day period immediately intent as expressed herein.
following the satisfaction of the eligibility
requirements of the Domestic Partnership. Serviced By
Termination of a Domestic Partner's Blue Cross and Blue Shield of Florida, Inc.
and/or Domestic Partner's Dependent
Child(ren)'s Coverage
In addition to the provisions stated in the
Termination of a Covered Dependent's
Coverage subsection of the Benefit Booklet,the
Covered Domestic Partner's and the Covered
Domestic Partner's Covered Dependent
child(ren)'s coverage under the Benefit Booklet
will terminate at 12:01 a.m. on the date that the
Domestic Partnership terminates or the date of
death of the Covered Domestic Partner. The
Covered Employee must notify the Group within
30 days of when Domestic Partnership eligibility
requirements are no longer met or within 30
days of the death of the Covered Domestic
Partner.
COBRA Continuation Of Coverage
Covered Domestic Partners are not entitled to
COBRA continuation of coverage but are eligible
under Monroe County employment/personnel
ASO Dom Part wfth Dep END
Plan 03559
2