Item F14 BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: November 20,2012 Division: Employee Services
Bulk Item: Yes X No Department: Employee Benefits
Staff Contact Person: Maria Gonzalez X4448
AGENDA ITEM WORDING:Approval of the Benefit Booklet and Summary Plan Document for
Covered Plan Participants of the Monroe County BOCC Group Health Plan
ITEM BACKGROUND: The Benefit Booklet and Summary Plan Documents reflect the change in
networks and describe how the interstate BlueCard networks are administered. The documents also
reflect the most current language that is in compliance with Health Care Reform and provides vendor
information and guidance for the employees when utilizing these benefits.
Staff, Blue Cross representatives, and the County's consultant have worked diligently since contracting
with the providers last year to ensure that all benefits are appropriately captured in these documents.
PREVIOUS REVELANT BOCC ACTION: On October 19, 2011, the BOCC approved the contract
with Blue Cross Blue Shield of Florida. On September 21, 2011, the BOCC approved the contract
with EnvisionRX Options.
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATIONS: Approval
TOTAL COST: N/A INDIRECT COST: BUDGETED: Yes No
COST TO COUNTY: N/A SOURCE OF FUNDS:
REVENUE PRODUCING: Yes o X AM UNT PER MONTH Year
APPROVED BY: County Att OMB/Pur�asing Risk Management �
DOCUMENTATION: Included X To Follow Not Required
DISPOSITION: AGENDA ITEM#
Revised 2/27/01
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—11/01111
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: BlueCard°(Out-of-State) Program ...........................................................7-1
Section 8: Blueprint for Health Programs..................................................................8-1
Section 9: Pre-existing Conditions Exclusion Period.................................................9-1
Section 10: Eligibility for Coverage............................................................................ 10-1
Section 11: Enrollment and Effective Date of Coverage............................................ 11-1
Section 12: Termination of Coverage........................................................................ 12-1
Section 13: Continuing Coverage Under COBRA..................................................... 13-1
Section 14: Conversion Privilege...................................................................14-1
Section 15: Extension of Benefits..................................................................15-1
Section 16: The Effect of Medicare Coverage/ Medicare Secondary Payer
Provisions .............................................................................................. 16-1
Section 17: Duplication of Coverage Under Other Health Plans/Programs............... 17-1
Section 18: Subrogation............................................................................................ 18-1
Section 19: Right of Reimbursement......................................................................... 19-1
Section 20: Claims Processing..................................................................................20-1
Section 21: Relationship Between the Parties...........................................................21-1
Section 22: General Provisions.................................................................................22-1
Section 23: Definitions...............................................................................................23-1
Table of Contents I
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 You will need to refer to the Schedule of
Plan")established and maintained by Monroe Benefits to determine how much you have to
County BOCC.
pay for particular Health Care Services.
The sponsor of your Group Health Plan has
contracted with Blue Cross Blue Shield of When reading your Booklet, please
Florida, Inc. (BCBSF), under an Administrative remember that:
Services Only Agreement("ASO Agreement"), • you should read this Booklet in its entirety in
to provide certain third party administrative order to determine if a particular Health Care
services, including claims processing, customer
Service is covered.
service, and other services, and access to
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 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 which 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 Dependent(s)will be
noted as such.
• your BlueOptions benefits;
• references to"we", "us", and`bur'throughout
• what is covered; 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
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 . what happens when your coverage ends?
Schedule of Benefits.
• 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 1-2
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
that are covered under this Benefit Booklet. All 4. in accordance with the benefit guidelines
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 (e.g.,
and/or exclusions,as well as other provisions Pre-existing Condition exclusionary period)
contained in this Booklet,and any or excluded under this Booklet.
Endorsement(s)in accordance with BCBSF's
Medical Necessity coverage criteria and benefit BCBSF or Monroe County BOCC will determine
guidelines then in effect. whether Services are Covered Services under
this Booklet after you have obtained the
Remember that exclusions and limitations also Services and a claim has been received for the
apply to your coverage. Exclusions and Services. In some circumstances BCBSF or
limitations that are specific to a type of Service Monroe County BOCC may determine whether
are included along with the benefit description in Services might be Covered Services under this
this section. Additional exclusions and Booklet before you are provided the Service.
limitations that may apply can be found in the For example, BCBSF or Monroe County BOCC
"What Is Not Covered?" section. More than one may determine whether a proposed transplant is
limitation or exclusion may apply to a specific a Covered Service under this Booklet before the
Service or a particular situation. transplant is provided. Neither BCBSF nor
Expenses for the Health Care Services listed in Monroe County BOCC are obligated to
this section will be covered under this Booklet determine, in advance,whether any Service not
only if the Services are: yet provided to you would be a Covered Service
unless we have specifically designated that a
1. within the Health Care Services categories Service is subject to a prior authorization
in the"What Is Covered?" section; requirement as described in the 'Blueprint for
2. actually rendered (not just proposed or Health Programs" section. We are also not
recommended)by an appropriately licensed obligated to cover or pay for any Service that
health care Provider who is recognized for has not actually been rendered to you.
payment under this Benefit Booklet and for In determining whether Health Care Services
which an itemized statement or description are Covered Services under this Booklet, no
of the procedure or Service which was written or verbal representation by any
rendered is received, including any employee or agent of BCBSF or Monroe County
applicable procedure code, diagnosis code BOCC, or by any other person, shall waive or
and other information required in order to otherwise modify the terms of this Booklet and,
process a claim for the Service; therefore, neither you, nor any health care
3. Medically Necessary, as defined in this Provider or other person should rely on any such
Booklet and determined by BCBSF in written or verbal representation.
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
critical; or
rendered.
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(e.g.,
injections)and the cost of hyposensitization oxygen);
serum are covered. The Allowed Amount for
allergy testing is based upon the type and
What Is Covered? 2-2
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
under Chapters 490 or 491 of the Florida
6. anesthetics and their administration; Statutes; 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 Autism Spectrum Disorder Services must be
Certified Registered Nurse Anesthetist("CRNA") authorized in accordance with BCBSF's
may be covered. In those instances where the established criteria, before such Services are
rendered. Services performed without
CRNA is actively directed by a Physician other authorization will be denied. Authorization for
than the Physician who performed the surgical coverage is not required when Covered Services
procedure, payment for Covered Services, if are provided for the treatment of an Emergency
any,will be made for both the CRNA and the Medical Condition.
Physician Health Care Services at the lower
directed-services Allowed Amount in accordance Note: In order to determine whether such
with BCBSF's payment program then in effect Services are covered under this Benefit Booklet,
for such Covered Services. we reserve the right to request a formal written
treatment plan signed by the treating Physician
Exclusion: to include the diagnosis,the proposed treatment
Coverage does not include anesthesia Services type,the frequency and duration of treatment,
by an operating Physician, his or her partner or the anticipated outcomes stated as goals, and
associate. the frequency with which the treatment plan will
be updated, but no less than every 6 months.
Autism Spectrum Disorder This Benefit Booklet will only cover services to
the extent included in the treating physician's
Autism Spectrum Disorder Services provided to formal written treatment plan.
a Covered Dependent who is under the age of Breast Reconstructive Surgery
18, or if 18 years of age or older, is attending
high school and was diagnosed with Autism Surgery to reestablish symmetry between two
Spectrum Disorder prior to his or her gth birthday breasts and implanted prostheses incident to
consisting of: Mastectomy is covered. In order to be covered,
such surgery must be provided in a manner
What Is Covered? 2-3
chosen by your Physician, consistent with 2. Extraction of teeth required prior to radiation
prevailing medical standards,and in consultation therapy when you have a diagnosis of
with you. cancer of the head and/or neck.
Child Cleft Lip and Cleft Palate Treatment 3. Anesthesia Services for dental care
including general anesthesia and
Treatment and Services for Child Cleft Lip and hospitalization Services necessary to assure
Cleft Palate, including medical, dental, Speech the safe delivery of necessary dental care
Therapy, audiology,and nutrition Services for provided to you or your Covered Dependent
treatment of a child under the age of 18 who has in a Hospital or Ambulatory Surgical Center
cleft lip or cleft palate are covered. In order for if:
such Services to be covered,your Covered
Dependent's Physician must specifically a) the Covered Dependent is under 8
prescribe such Services and such Services must years of age and it is determined by a
be medically necessary and consequent to dentist and the Covered Dependent's
treatment of the cleft lip or cleft palate. Physician that:
Concurrent Physician Care i. dental treatment is necessary due to
a dental Condition that is
Concurrent Physician care Services are significantly complex; or
covered, provided: (a)the additional Physician
actively participates in your treatment; (b)the ii. the Covered Dependent has a
Condition involves more than one body system developmental disability in which
or is so severe or complex that one Physician patient management in the dental
cannot provide the care unassisted;and (c)the office has proven to be ineffective;
Physicians have different specialties or have the or
same specialty with different sub-specialties. b) you or your Covered Dependent have
one or more medical Conditions that
Consultations would create significant or undue
Consultations provided by a Physician are medical risk for you in the course of
covered if your attending Physician requests the delivery of any necessary dental
consultation and the consulting Physician treatment or surgery if not rendered in a
prepares a written report. Hospital or Ambulatory Surgical Center.
Contraceptive Injections Exclusion:
Medication by injection is covered when 1. Dental Services provided more than 90
provided and administered by a Physician,for days after the date of an Accidental
the purpose of contraception, and is limited to Dental Injury regardless of whether or
the medication and administration when not such services could have been
medically necessary. rendered within 90 days; and
Dental Services 2. Dental Implant.
Dental Services are limited to the following: Diabetes Outpatient Self-Management
1. Care and stabilization treatment rendered Diabetes outpatient self-management training
within 90 days of an Accidental Dental Injury
and educational Services and nutrition
to Sound Natural Teeth.
counseling (including all Medically Necessary
equipment and supplies)to treat diabetes, if
What Is Covered? 2-4
your treating Physician or a Physician who Durable Medical Equipment
specializes in the treatment of diabetes certifies Durable Medical Equipment when provided by a
that such Services are Medically Necessary, are
Durable Medical Equipment Provider and when
covered. In order to be covered,diabetes prescribed by a Physician, limited to the most
outpatient self-management training and cost-effective equipment as determined by
educational Services must be provided under BCBSF or Monroe County BOCC is covered.
the direct supervision of a certified Diabetes
Educator or a board-certified Physician Payment Guidelines for Durable Medical
specializing in endocrinology. Additionally, in Equipment
order to be covered, nutrition counseling must Supplies and service to repair medical
be provided by a licensed Dietitian. Covered equipment may be Covered Services only if you
Services may also include the trimming of own the equipment or you are purchasing the
toenails, corns, calluses,and therapeutic shoes equipment. Payment for Durable Medical
(including inserts and/or modifications)for the Equipment will be based on the lowest of the
treatment of severe diabetic foot disease. following: 1)the purchase price; 2)the
Diagnostic Services lease/purchase price; 3)the rental rate; or 4)the
Allowed Amount. The Allowed Amount for such
Diagnostic Services when ordered by a rental equipment will not exceed the total
Physician are limited to the following: purchase price. Durable Medical Equipment
1. radiology, ultrasound and nuclear medicine, includes, but is not limited to,the following:
Magnetic Resonance Imaging (MRI); wheelchairs, crutches, canes,walkers, hospital
2. laboratory and pathology Services; beds, and oxygen equipment.
3. Services involving bones or joints of the jaw 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 Exclusion:
Conditions caused by congenital or Equipment which is primarily for convenience
developmental deformity, disease, or injury; and/or comfort; modifications to motor vehicles
4. approved machine testing (e.g., and/or homes, including but not limited to,
electrocardiogram [EKG], wheelchair lifts or ramps;water therapy devices
electroencephalograph [EEG], and other such as Jacuzzis, hot tubs, swimming pools or
electronic diagnostic medical procedures); whirlpools; exercise and massage equipment,
and 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
What is Covered? 2-5
Emergency Services for an Emergency Medical (e.g., radial keratotomy, PRK and LASIK)are
Condition are covered when rendered In- excluded.
Network and Out-of-Network without the need
for any prior authorization determination by us. Home Health Care
When Emergency Services and care for an The Home Health Care Services listed below
Emergency Medical Condition are rendered by are covered when the following criteria are met:
an Out-of-Network Provider, any Copayment 1. you are unable to leave your home without
and/or Coinsurance amount applicable to In- considerable effort and the assistance of
Network Providers for Emergency Services will another person because you are: bedridden
also apply to such Out-of-Network Provider. 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
diseases of amino acid, organic acid, 2• the Home Health Care Services rendered
carbohydrate or fat metabolism as well as have been prescribed by a Physician by way
malabsorption originating from congenital of a formal written treatment plan that has
defects present at birth or acquired during the been reviewed and renewed by 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
1. Physician Services, soft lenses or sclera 4. you are meeting or achieving the desired
shells,for the treatment of aphakic patients; treatment goals set forth in the treatment
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
disease of the eyes. 1. part-time(i.e., less than 8 hours per day and
less than a total of 40 hours in a calendar
Exclusion:
week)or intermittent(i.e., a visit of up to, but
Health Care Services to diagnose or treat vision not exceeding, 2 hours per day) nursing
problems which are not a direct consequence of care by a Registered Nurse, Licensed
trauma or prior ophthalmic surgery; eye Practical Nurse and/or home health aide
examinations; eye exercises or visual training; Services;
eye glasses and contact lenses and their fitting
are excluded. In addition to the above, any 2. home health aide Services must be
surgical procedure performed primarily to correct consistent with the plan of treatment,
or improve myopia or other refractive disorders
What Is Covered? 2-6
ordered by a Physician, and rendered under 1. room and board in a semi-private room
the supervision of a Registered Nurse; when confined as an inpatient, unless the
patient must be isolated from others for
3. medical social services; documented clinical reasons;
4. nutritional guidance; 2. intensive care units, including cardiac,
5. respiratory, or inhalation therapy(e.g., progressive and neonatal care;
oxygen); and 3. use of operating and recovery rooms;
6. Physical Therapy by a Physical Therapist, 4. use of emergency rooms;
Occupational Therapy by a Occupational
Therapist, and Speech Therapy by a 5. respiratory, pulmonary, or inhalation therapy
Speech Therapist. (e.g.,oxygen);
Exclusions: 6. drugs and medicines administered(except
for take home drugs)by the Hospital;
1. homemaker or domestic maid services;
7. intravenous solutions;
2. sitter or companion services;
8. administration of, including the cost of,
3. Services rendered by an employee or whole blood or blood products(except as
operator of an adult congregate living outlined in the Drugs exclusion of the"What
facility; an adult foster home; an adult day Is Not Covered?"section);
care center, or a nursing home facility;
9. dressings, including ordinary casts;
4. Speech Therapy provided for a diagnosis of
10. anesthetics and their administration;
developmental delay;
5. Custodial Care except for any such care 11. transfusion supplies and equipment;
covered under this subsection when 12. diagnostic Services, including radiology,
provided on a part-time or intermittent basis ultrasound, laboratory, pathology and
(as defined above) by a home health aide; approved machine testing (e.g., EKG);
6. food, housing, and home delivered meals; 13. Physical, Speech, Occupational, and
and Cardiac Therapies; and
7. Services rendered in a Hospital, nursing 14. transplants as described in the Transplant
home, or intermediate care facility. Services subsection.
Hospice Services Exclusion:
Health Care Services provided in connection Expenses for the following Hospital Services are
with a Hospice treatment program may be excluded when such Services could have been
Covered Services, provided the Hospice provided without admitting you to the Hospital:
treatment program is: 1) room and board provided during the
admission;2)Physician visits provided while you
1. approved by your Physician; and were an inpatient;3)Occupational Therapy,
2. your doctor has certified to us in writing that Speech Therapy, Physical Therapy, and Cardiac
your life expectancy is 12 months or less. Therapy; and 4)other Services provided while
you were an inpatient.
Recertification is required every six months.
In addition, expenses for the following and
Hospital Services similar items are also excluded:
Covered Hospital Services include: 1. gowns and slippers;
What Is Covered? 2-7
2. shampoo,toothpaste, body lotions and respiratory ventilator management Services are
hygiene packets; excluded.
3. take-home drugs; Mammograms
4. telephone and television;
Mammograms obtained in a medical office,
5. guest meals or gourmet menus; and medical treatment facility or through a health
6. admission kits. testing service that uses radiological equipment
registered with the appropriate Florida regulatory
Inpatient Rehabilitation agencies(or those of another state)for
diagnostic purposes or breast cancer screening
Inpatient Rehabilitation Services are covered are Covered Services.
when the following criteria are met:
Benefits for mammograms may not be subject to
1. Services must be provided under the the Deductible, Coinsurance, or Copayment(if
direction of a Physician and must be applicable). Please refer to your Schedule of
provided by a Medicare certified facility in Benefits for more information.
accordance with a comprehensive
rehabilitation program; Mastectomy Services
2. a plan of care must be developed and Breast cancer treatment including treatment for
managed by a coordinated multi-disciplinary physical complications relating to a Mastectomy
team; (including lymphedemas), and outpatient post-
3. coverage is limited to the specific acute, surgical follow-up in accordance with prevailing
catastrophic target diagnoses of severe medical standards as determined by you and
stroke, multiple trauma, brain/spinal injury, your attending Physician are covered.
severe neurological motor disorders, and/or Outpatient post-surgical follow-up care for
severe burns; Mastectomy Services shall be covered when
provided by a Provider in accordance with the
4. the individual must be able to actively prevailing medical standards and at the most
participate in at least 2 rehabilitative medically appropriate setting. The setting may
therapies and be able to tolerate at least 3 be the Hospital, Physician's office, outpatient
hours per day of skilled Rehabilitation center, or your home. The treating Physician,
Services for at least 5 days a week and their after consultation with you, may choose the
Condition must be likely to result in appropriate setting.
significant improvement; and
5. the Rehabilitation Services must be required Maternity Services
at such intensity,frequency and duration as Health Care Services, including prenatal care,
to make it impractical for the individual to delivery and postpartum care and assessment,
receive services in 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.
Exclusion: In order for the postpartum assessment to be
covered, such assessment must be provided at
All Substance Dependency, drug and alcohol a Hospital, an attending Physician's office, an
related diagnoses, Pain Management, and
What Is Covered? 2-8
outpatient maternity center, or in the home by a include the administration of the Prescription
qualified licensed health care professional Drug.
trained in care for a mother. Coverage under
this Booklet for the postpartum assessment Your plan may also include a maximum monthly
includes coverage for the physical assessment amount you will be required to pay out-of-pocket
of the mother and any necessary clinical tests in for Medical Pharmacy,when such Services are
keeping with prevailing medical standards. provided by an In-Network Provider or Specialty
Pharmacy. If your plan includes a Medical
Under Federal law, your Group Plan generally Pharmacy out-of-pocket monthly maximum, it
may not restrict benefits for any hospital length will be listed on your Schedule of Benefits and
of stay in connection with childbirth for the only applies after you have met your Deductible,
mother or newborn child to less than 48 hours if applicable.
following a vaginal delivery; or less than 96
hours following a cesarean section. However, Please refer to your Schedule of Benefits for the
Federal law generally does not prohibit the additional Cost Share amount and/or monthly
mother's or newborn's attending Provider, after maximum out-of-pocket applicable to Medical
consulting with the mother,from discharging the Pharmacy for your plan.
mother or her newborn earlier than 48 hours(or Note: For purposes of this benefit, allergy
96 as applicable). In any case, under Federal injections and immunizations are not considered
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 Mental Health Services
96 hours).
Diagnostic evaluation, psychiatric treatment,
Exclusion: individual therapy, and group therapy provided
Maternity Services rendered to a Covered to you by a Physician, Psychologist, or Mental
Person who becomes pregnant as a Gestational Health Professional for the treatment of a Mental
Surrogate under the terms of, and in accordance and Nervous Disorder may be covered. These
with, a Gestational Surrogacy Contract or Health Care Services include inpatient,
Arrangement are excluded. This exclusion outpatient, and Partial Hospitalization services.
applies to all expenses for prenatal, intra-partal, Partial Hospitalization is a Covered Service
and post-partal Maternity/Obstetrical Care, and when provided under the direction of a Physician
Health Care Services rendered to the Covered and in lieu of inpatient hospitalization.
Person acting as a Gestational Surrogate.
Exclusion:
For the definition of Gestational Surrogate and
Gestational Surrogacy Contract, see the 1. Services rendered in connection with a
"Definitions" section of this Benefit Booklet. Condition not classified in the diagnostic
categories of the International Classification
Medical Pharmacy of Diseases, Ninth Edition, Clinical
Modification(ICD-9 CM)or their equivalents
Physician-administered Prescription Drugs in the most recently published version of the
which are rendered in a Physician's office are American Psychiatric Association's
subject to a separate Cost Share amount that is Diagnostic and Statistical Manual of Mental
in addition to the office visit Cost Share amount. Disorders, regardless of the underlying
The Medical Pharmacy Cost Share amount cause, or effect, of the disorder;
applies to the Prescription Drug and does not
What Is Covered? 2-9
2. Services for psychological testing An assessment of the newborn child is covered
associated with the evaluation and diagnosis provided the Services were rendered at a
of learning disabilities or for mental Hospital,the attending Physician's office,a Birth
retardation; Center, or in the home by a Physician, Midwife
or Certified Nurse Midwife, and the performance
3. Services extended beyond the period of any necessary clinical tests and
necessary for evaluation and diagnosis of immunizations are within prevailing medical
learning disabilities or for mental retardation; standards. These Services are not subject to
4. Services for marriage counseling, when not the Deductible.
rendered in connection with a Condition Ambulance Services,when necessary to
classified in the diagnostic categories of the transport the newborn child to and from the
International Classification of Diseases, nearest appropriate facility which is staffed and
Ninth Edition, Clinical Modification (ICD-9-
CM)or their equivalents in the most recently equipped to treat the newborn child's Condition,
published version of the American as determined by BCBSF or Monroe County
Psychiatric Association's Diagnostic and BOCC and certified by the attending Physician
Statistical Manual of Mental Disorders; as Medically Necessary to protect the health and
5. Services for pre-marital counseling; safety of the newborn child, are covered.
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
10. inpatient confinements that are primarily law, your Group Plan can only require that a
intended as a change of environment;or provider obtain authorization for prescribing an
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
A newborn child will be covered from the Orthotic Devices including braces and trusses
moment of birth provided that the newborn child for the leg, arm, neck and back,and special
is eligible for coverage and properly enrolled. surgical corsets are covered when prescribed by
Covered Services shall consist of coverage for a Physician and designed and fitted by an
injury or sickness, including the necessary care Orthotist.
or treatment of medically diagnosed congenital Benefits may be provided for necessary
defects, birth abnormalities, and premature birth. replacement of an Orthotic Device which is
Newborn Assessment: owned by you when due to irreparable damage,
wear, a change in your Condition, or when
necessitated due to growth of a child.
What Is Covered? 2-10
Payment for splints for the treatment of 2. individuals who have vertebral
temporomandibular joint("TMJ")dysfunction is abnormalities;
limited to payment for one splint in a six-month 3. individuals who are receiving long-term
period unless a more frequent replacement is glucocorticoid(steroid)therapy;
determined by BCBSF or Monroe County BOCC
to be Medically Necessary. 4. individuals who have primary
hyperparathyroidism;and
Exclusion: 5. individuals who have a family history of
osteoporosis.
1. Expenses for arch supports,shoe inserts
designed to effect conformational changes Outpatient Cardiac,Occupational, Physical,
in the foot or foot alignment, orthopedic Speech, Massage Therapies and Spinal
shoes, over-the-counter, custom-made or Manipulation Services
built-up shoes, cast shoes, sneakers, ready- Outpatient therapies listed below may be
made compression hose or support hose, or Covered Services when ordered by a Physician
similar type devices/appliances regardless or other health care professional licensed to
of intended use, except for therapeutic perform such Services. The outpatient therapies
shoes (including inserts and/or listed in this category are in addition to the
modifications)for the treatment of severe Cardiac, Occupational, Physical and Speech
diabetic foot disease; Therapy benefits listed in the Home Health
2. Expenses for orthotic appliances or devices Care, Hospital, and Skilled Nursing Facility
which straighten or re-shape the categories herein.
conformation of the head or bones of the Cardiac Therapy Services provided under the
skull or cranium through cranial banding or supervision of a Physician, or an appropriate
molding (e.g.dynamic orthotic cranioplasty Provider trained for Cardiac Therapy,for the
or molding helmets), except when the purpose of aiding in the restoration of normal
orthotic appliance or device is used as an heart function in connection with a myocardial
alternative to an internal fixation device as a infarction, coronary occlusion or coronary
result of surgery for craniosynostosis;and bypass surgery are covered.
3. Expenses for devices necessary to exercise, Occupational Therapy Services provided by a
train, or participate in sports,e.g.custom- Physician or Occupational Therapist for the
made knee braces. purpose of aiding in the restoration of a
previously impaired function lost due to a
Osteoporosis Screening, Diagnosis, and Condition are covered.
Treatment Speech Therapy Services of a Physician,
Screening, diagnosis, and treatment of Speech Therapist, or licensed audiologist to aid
osteoporosis for high-risk individuals is covered in the restoration of speech loss or an
as medically necessary, including, but not impairment of speech resulting from a Condition
are covered.
limited to:
Physical Therapy Services provided by a
1. estrogen-deficient individuals who are at Physician or Physical Therapist for the purpose
clinical risk for osteoporosis; of aiding in the restoration of normal physical
function lost due to a Condition are covered.
What Is Covered? 2-11
Massage Therapy Massage provided by a maximum benefit listed in the Schedule of
Physician, Massage Therapist, or Physical Benefits,whichever occurs first.
Therapist when the Massage is prescribed as 2. Payment for covered Physical Therapy
being Medically Necessary by a Physician Services rendered on the same day as
licensed pursuant to Florida Statutes Chapter spinal manipulation is limited to one(1)
458(Medical Practice), Chapter 459 Physical Therapy treatment per day, not to
(Osteopathy), Chapter 460 (Chiropractic)or
C exceed fifteen (15)minutes in length.
Chapter 461 (Podiatry) is covered. The
Physician's prescription must specify the Your Schedule of Benefits sets forth the
number of treatments. maximum number of visits covered under this
Payment Guidelines for Massage and plan for any combination of the outpatient
Physical Therapy therapies and spinal manipulation Services
listed above. For example, even if you may
1. Payment for covered Massage Services is have only been administered two(2)of the
limited to no more than four(4) 15-minute spinal manipulations for the Benefit Period,any
Massage treatments per day, not to exceed 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 of Benefits.
2. Payment for a combination of covered Oxygen
Massage and Physical Therapy Services Expenses for oxygen, the equipment necessary
rendered on the same day is limited to no to administer it, and the administration of oxygen
more than four(4) 15-minute treatments per are covered.
day for combined Massage and Physical
Therapy treatment, not to exceed the Physician Services
Outpatient Cardiac, Occupational, Physical, Medical or surgical Health Care Services
Speech, and Massage Therapies and Spinal provided by a Physician, including Services
Manipulations benefit maximum listed on the rendered in the Physician's office, in an
Schedule of Benefits. outpatient facility, or electronically through a
3. Payment for covered Physical Therapy computer via the Internet.
Services rendered on the same day as
spinal manipulation is limited to one(1) Payment Guidelines for Physician Services
Provided by Electronic Means through a
Physical Therapy treatment per day not to
Computer:
exceed fifteen(15)minutes in length.
Spinal Manipulations: Services by Physicians Expenses for online medical Services provided
for manipulations of the spine to correct a slight electronically through a computer by a Physician
dislocation of a bone or joint that is via the Internet will be covered only if such
demonstrated by x-ray are covered. Services:
Payment Guidelines for Spinal Manipulation 1. were provided to a covered individual who
was, at the time the Services were provided,
1. Payment for covered spinal manipulation is an established patient of the Physician
limited to no more than 26 spinal rendering the Services;
manipulations per Benefit Period, or the
What Is Covered? 2-12
2. were in response to an online inquiry Committee on Immunization Practices of the
received through the Internet from the Centers for Disease Control and Prevention
covered individual with respect to which the established under the Public Health Service
Services were provided; and Act with respect to the individual involved;
3. were provided by a Physician through a and
secure online healthcare communication 3. with respect to women, such additional
services vendor that,at the time the preventive care and screenings not
Services were rendered,was under contract described in paragraph (1)as provided for in
with BCBSF. comprehensive guidelines supported by the
The term "established patient,"as used herein, Health Resources and Services
shall mean that the covered individual has Administration.
received professional services from the Exclusion:
Physician who provided the online medical
Services, or another physician of the same Routine vision and hearing examinations and
specialty who belongs to the same group screenings are not covered, except as required
practice as that Physician,within the past three under paragraph number one above.
years.
Preventive Child Health Supervision Services
Exclusion:
Preventive Child Health Supervision Services
Expenses for online medical Services provided from the moment of birth up to the 17th birthday
electronically through a computer by a Physician are covered.
via the Internet other than through a healthcare
communication services vendor that has entered In order to be covered,Services shall be
into contract with BCBSF are excluded. provided in accordance with prevailing medical
Expenses for online medical Services provided standards consistent with:
by a health care provider that is not a Physician 1. evidence-based items or Services that have
and expenses for Health Care Services in effect a rating of`A'or`B' in the current
rendered by telephone are also excluded. recommendations of the U.S. Preventive
Services Task Force established under the
Preventive Adult Wellness Services Public Health Service Act;
Preventive adult wellness Services are covered 2. Immunizations that have in effect a
under your plan. For purposes of this benefit, an recommendation from the Advisory
adult is 17 years or older. Committee on Immunization Practices of the
In order to be covered, Services shall be Centers for Disease Control and Prevention
provided in accordance with prevailing medical established under the Public Health Service
standards consistent with: Act with respect to the individual involved;
and
1. evidence-based items or Services that have
in effect a rating of'A'or`B' in the current 3. with respect to infants, children, and
recommendations of the U.S. Preventive adolescents, evidence-informed preventive
care and screenings provided for in the
Services Task Force established under the
comprehensive guidelines supported by the
Public Health Service Act; Health Resources and Services
2. immunizations that have in effect a Administration.
recommendation from the Advisory Prosthetic Devices
What Is Covered? 2-13
The following Prosthetic Devices are covered Specialty Pharmacy or an Out-of-Network
when prescribed by a Physician and designed Provider that provides Specialty Drugs.
and fitted by a Prosthetist:
3. Specialty Drugs used to increase height or
1. artificial hands, arms,feet, legs and eyes, bone growth (e.g., growth hormone), must
including permanent implanted lenses meet the following criteria in order to be
following cataract surgery, cardiac
covered:
pacemakers, and prosthetic devices incident
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
tests of less than 10 ng/ml and one
3. penile prosthesis. abnormally low growth hormone
Covered Prosthetic Devices(except cardiac dependent peptide or for Conditions of
pacemakers,and Prosthetic Devices incident to growth hormone deficiency associated
Mastectomy)are limited to the first such with loss of pituitary function due to
permanent prosthesis(including the first trauma, surgery,tumors, radiation or
temporary prosthesis if it is determined to be disease, or for state mandated use as in
necessary)prescribed for each specific patients with AIDS.
Condition.
b. Continuation of growth hormone therapy
Benefits may be provided for necessary is only covered for Conditions
replacement of a Prosthetic Device which is associated with significant growth
owned by you when due to irreparable damage, hormone deficiency when there is
wear, or a change in your Condition, or when evidence of continued responsiveness
necessitated due to growth of a child. to treatment. Treatment is considered
Exclusion: 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 cm 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:
symbol in the Medication Guide when 1. room and board;
delivered to you at home and purchased at a
What Is Covered? 2-14
2. respiratory, pulmonary, or inhalation therapy 2. Physician, Psychologist and Mental Health
(e.g., oxygen); Professional outpatient visits for the care
3. drugs and medicines administered while an and treatment of Substance Dependency.
inpatient(except take home drugs); Exclusion:
4. intravenous solutions; Expenses for prolonged care and treatment of
Substance Dependency in a specialized
5. administration of, including the cost of, inpatient or residential facility or inpatient
whole blood or blood products(except as
outlined in the Drugs exclusion of the"What confinements that are primarily intended as a
Is Not Covered?" section); change of environment are excluded.
6. dressings, including ordinary casts; Surgical Assistant Services
7. transfusion supplies and equipment; Services rendered by a Physician, Registered
Nurse First Assistant or Physician Assistant
8. diagnostic Services, including radiology, when acting as a surgical assistant(provided no
ultrasound, laboratory, pathology and intern, resident, or other staff physician is
approved machine testing (e.g., EKG); available)when the assistant is necessary are
9. chemotherapy treatment for proven covered.
malignant disease; and Surgical Procedures
10. Physical, Speech, and Occupational Surgical procedures performed by a Physician
Therapies; may be covered including the following:
A treatment plan from your Physician may be 1. sterilization (tubal ligations and
required in order to determine coverage and vasectomies), regardless of Medical
payment. Necessity;
Exclusion: 2. surgery to correct deformity which was
Expenses for an inpatient admission to a Skilled caused by disease, trauma, birth defects,
Nursing Facility for purposes of Custodial Care, growth defects or prior therapeutic
convalescent care, or any other Service processes;
primarily for the convenience of you and/or your 3. oral surgical procedures for excisions of
family members or the Provider are excluded. tumors,cysts, abscesses, and lesions of the
mouth;
Substance Dependency Care and Treatment
4. surgical procedures involving bones or joints
Care and treatment for Substance Dependency of the jaw(e.g.,temporomandibular joint
includes the following: [TMJ])and facial region if, under accepted
1. Health Care Services(inpatient and medical standards, such surgery is
outpatient or any combination thereof) necessary to treat Conditions caused by
provided by a Physician, Psychologist or congenital or developmental deformity,
Mental Health Professional in a program disease, or injury; and
accredited by the Joint Commission on the 5. Services of a Physician for the purpose of
Accreditation of Healthcare Organizations or rendering a second surgical opinion and
approved by the state of Florida(or another related diagnostic services to help determine
state)for Detoxification or Substance the need for surgery.
Dependency.
What Is Covered? 2-15
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 BCBSF's or Monroe
necessary. County BOCC's opinion, is not clearly
Exclusion: identified and/or does not add significant
a. Surgical procedures for the treatment of time or complexity to the surgical session.
F
Morbid Obesity including: intestinal or example,the removal of a normal
bypass; stomach stapling; balloon appendix performed in conjunction with a
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
previously undergone the same or appendix in the example).
similar procedures in the lifetime of this 3. Payment for surgical procedures for fracture
Group Health Plan. Surgical procedures care, 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,
surgical procedures to revise, correct, Transplant Services, limited to the procedures
and correction of defects to include listed below, may be covered when performed at
adjustment to devices implanted or any a facility acceptable to BCBSF or Monroe
fills not performed during the initial County BOCC, subject to the conditions and
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
will be based on 50 percent of the Allowed 1. Bone Marrow Transplant,as defined herein,
Amount for any secondary surgical which is specifically listed in the rule 5913-
procedure(s)performed. In addition, 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
provided for the expenses incurred for the
2. Payment for incidental surgical procedures donation of bone marrow by a donor to the
is limited to the Allowed Amount for the
What Is Covered? 2-16
same extent such expenses would be 2. transplant procedures involving the
covered for you and will be subject to the transplantation or implantation of any non-
same limitations and exclusions as would be human organ or tissue;
applicable to you. Coverage for the 3. transplant procedures related to the donation
reasonable expenses of searching for the or acquisition of an organ or tissue for a
donor will be limited to a search among recipient who is not covered under this
immediate family members and donors Benefit Booklet;
identified through the National Bone Marrow
Donor Program; 4. transplant procedures involving the implant of
an artificial organ, including the implant of the
2. corneal transplant;
artificial organ;
3. heart transplant(including a ventricular
5. any organ,tissue, marrow, or stem cells
assist device, if indicated,when used as a which is/are sold rather than donated;
bridge to heart transplantation);
6. any Bone Marrow Transplant, as defined
4. heart-lung combination transplant; herein,which is not specifically listed in rule
5. liver transplant; 5913-12.001 of the Florida Administrative
6. kidney transplant; Code or any successor or similar rule or
covered by Medicare pursuant to a national
7. pancreas; coverage decision made by the Centers for
8. pancreas transplant performed Medicare and Medicaid Services as
simultaneously with a kidney transplant; or evidenced in the most recently published
Medicare Coverage Issues Manual;
9. lung-whole single or whole bilateral
transplant. 7.:any Service in connection with the
identification of a donor from a local, state or
Coverage will be provided for donor costs and national listing, except in the case of a Bone
organ acquisition for transplants, other than Marrow Transplant;
Bone Marrow Transplants, provided such costs
are not covered in whole or in part by any other 8. any non-medical costs, including but not
insurance carrier, organization or person other limited to,temporary lodging or transportation
than the donor's family or estate. costs for you and/or your family to and from
the approved facility; and
You may call the customer service phone
number indicated in this Booklet or on your 9. any artificial heart or mechanical device that
Identification Card in order to determine which replaces either the atrium and/or the
Bone Marrow Transplants are covered under ventricle.
this Booklet.
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);
What Is Covered? 2-17
Section 3: What Is Not Covered?
Introduction modifications and purification therapies;
traditional Oriental medicine including
Your Booklet expressly excludes expenses for acupuncture; naturopathic medicine;
the following Health Care Services, supplies, environmental medicine including the field of
drugs or charges. The following exclusions are clinical ecology; chelation therapy;
in addition to any exclusions specified in the thermography; mind-body interactions such as
"What Is Covered?" section or any other section meditation, imagery, yoga, dance, and art
of the Booklet. therapy; biofeedback; prayer and mental
Abortions which are elective. healing; manual healing methods such as the
Alexander technique, aromatherapy,Ayurvedic
Adult Wellness preventive care or routine massage,craniosacral balancing, Feldenkrais
screening Services, except as specified under method, Hellerwork, polarity therapy, Reichian
the Preventive Adult Wellness Services category therapy, reflexology, rolfing, shiatsu, traditional
on the Schedule of Benefits. 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, bioelectromagnetic applications in medicine; and
custom-made or built-up shoes, cast shoes, herbal therapies.
sneakers, ready-made compression hose or Complications of Non-Covered Services,
support hose, or similar type devices/appliances including the diagnosis or treatment of any
regardless of intended use, except for Condition which is a complication of a non-
therapeutic shoes (including inserts and/or covered Health Care Service (e.g., Health Care
modifications)for the treatment of severe Services to treat a complication of cosmetic
diabetic foot disease. surgery are not covered).
Assisted Reproductive Therapy(Infertility) Contraceptive medications, devices,
including, but not limited to, associated Services, appliances, or other Health Care Services when
supplies,and medications for In Vitro provided for contraception, except when
Fertilization (IVF); Gamete Intrafallopian indicated as covered, under the adult wellness
Transfer(GIFT) procedures;Zygote benefit, on the Schedule of Benefits(when
Intrafallopian Transfer(ZIFT)procedures; selected by the Group), or otherwise covered in
Artificial Insemination (AI); embryo transport; the"What Is Covered?" section.
surrogate parenting; donor semen and related
costs including collection and preparation; and Cosmetic Services, including any Service to
infertility treatment medication. improve the appearance or self-perception of an
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
Complementary or Alternative Medicine skin wrinkling(e.g., Minoxidil, Rogaine, Retin-A),
including, but not limited to, self-care or self-help
and hair implants/transplants.
training; homeopathic medicine and counseling;
Ayurvedic medicine such as lifestyle
What Is Not Covered? 3-1
Costs related to telephone consultations,failure for at least one indication, provided the drug
to keep a scheduled appointment, or completion is recognized for treatment of your particular
of any form and/or medical information. cancer in a Standard Reference
Custodial Care and any service of a custodial Compendium or recommended for treatment
of your particular cancer in Medical
nature, including and without limitation: Health Literature. Drugs prescribed for the
Care Services primarily to assist in the activities treatment of cancer that have not been
of daily living; rest homes; home companions or
approved for any indication are excluded.
sitters; home parents; domestic maid services;
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 from a pharmacy. This exclusion does not
member or caregiver of a Covered Person to apply to drugs dispensed to you when:
return to work. a. you are an inpatient in a Hospital,
Dental Care or treatment of the teeth or their Ambulatory Surgical Center, Skilled
supporting structures or gums, or dental Nursing Facility, Psychiatric Facility or a
procedures, including but not limited to: Hospice facility;
extraction of teeth, restoration of teeth with or b. you are in the outpatient department of
without fillings, crowns or other materials, a Hospital;
bridges,cleaning of teeth, dental implants,
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);
exclusion also applies to Phase II treatments(as d. you are receiving Home Health Care
defined by the American Dental Association)for according to a plan of treatment and the
TMJ dysfunction. This exclusion does not apply Home Health Care Agency bills us for
to an Accidental Dental Injury and the Child Cleft such drugs, including Self-Administered
Lip and Cleft Palate Treatment Services Prescription Drugs that are rendered in
category as described in the"What Is Covered?" connection with a nursing visit.
section.
3. Any non-Prescription medicines, remedies,
Drugs vaccines, biological products(except
insulin), pharmaceuticals or chemical
1. Prescribed for uses other than the Food and compounds,vitamins, mineral supplements,
Drug Administration(FDA)approved label fluoride products, over-the-counter drugs,
indications. This exclusion does not apply to products, or health foods, except as
any drug that has been proven safe, described in the Preventive Adult Wellness
effective and accepted for the treatment of Services and Preventive Child Health
the specific medical Condition for which the Supervision Services categories of the
drug has been prescribed, as evidenced by "What Is Covered?"section.
the results of good quality controlled clinical
studies published in at least two or more 4. Any drug which is indicated or used for
peer-reviewed full length articles in sexual dysfunction (e.g., Cialis, Levitra,
respected national professional medical Viagra, Caverject). The exception described
journals. This exclusion also does not apply in exclusion number one above does not
to any drug prescribed for the treatment of apply to sexual dysfunction drugs excluded
cancer that has been approved by the FDA under this paragraph.
What Is Not Covered? 3-2
5. Any Self-Administered Prescription Drug not Food and Food Products prescribed or not,
indicated as covered in the "What Is except as covered in the Enteral Formulas
Covered?" section of this Benefit Booklet. subsection of the"What Is Covered?" section.
6. Blood or blood products used to treat Foot Care which is routine, including any Health
hemophilia, except when provided to you Care Service, in the absence of disease. This
for: exclusion includes, but is not limited to: non-
a. emergency stabilization; surgical treatment of bunions;flat feet;fallen
arches; chronic foot strain;trimming of toenails
b. during a covered inpatient stay, or corns, or calluses.
c. when proximately related to a surgical General Exclusions include, but are not limited
procedure. to:
The exceptions to the exclusion for drugs 1. any Health Care Service received prior to
purchased or dispensed by a pharmacy your Effective Date or after the date your
described in subparagraph number two do coverage terminates;
not apply to hemophilia drugs excluded
under this subparagraph. 2. any Service to diagnose or treat any
Condition resulting from or in connection
7. Drugs,which require prior coverage with your job or employment;
authorization when prior coverage
authorization is not obtained. 3. any Health Care Services not within the
service categories described in the "What is
8. Specialty Drugs used to increase height or Covered?"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 to be
documented with two abnormally low
covered by applicable law;
stimulation tests of less than 10 ng/ml and
one abnormally low growth hormone 4. any Health Care Services provided by a
dependent peptide or for Conditions of Physician or other health care Provider
growth hormone deficiency associated with related to you by blood or marriage;
loss of pituitary function due to trauma, 5. any Health Care Service which is not
surgery,tumors, radiation or disease, or for Medically Necessary as determined by us or
state mandated use as in patients with Monroe County BOCC and defined in this
AIDS. Booklet. The ordering of a Service by a
Continuation of growth hormone therapy will health care Provider does not in itself make
not be covered except for Conditions such Service Medically Necessary or a
associated with significant growth hormone Covered Service;
deficiency when there is evidence of 6. any Health Care Services rendered at no
continued responsiveness to treatment. charge;
(See"What is Covered?"section for
additional information.) 7. expenses for claims denied because we did
not receive information requested from you
Experimental or Investigational Services, regarding whether or not you have other
except as otherwise covered under the Bone coverage and the details of such coverage;
Marrow Transplant provision of the Transplant
Services category.
What Is Not Covered? 3-3
8. any Health Care Services to diagnose or Hearing Aids(external or implantable)and
treat a Condition which, directly or indirectly, Services related to the fitting or provision of
resulted from or is in connection with: hearing aids, including tinnitus maskers,
a) war or an act of war,whether declared batteries, and cost of repair.
or not; Immunizations except those covered under the
b) your participation in, or commission of, Preventive Child Health Supervision Services or
any act punishable by law as a Preventive Adult Wellness Services categories
misdemeanor or felony, or which of the"What Is Covered?" section.
constitutes riot, or rebellion; Maternity Services rendered to a Covered
c) your engaging in an illegal occupation; Person who becomes pregnant as a Gestational
d) Services received at military or Surrogate under the terms of, and in accordance
government facilities; or with, a Gestational Surrogacy Contract or
e) Services received to treat a Condition Arrangement. This exclusion applies to all
arising out of your service in the armed expenses for prenatal, intra-partal, and post-
forces, reserves and/or National Guard; partal Maternity/Obstetrical Care, and Health
Care Services rendered to the Covered Person
f) Services that are not patient-specific,as
acting as a Gestational Surrogate.
determined solely by us.
9. Health Care Services rendered because For the definition of Gestational Surrogate and
they were ordered by a court, unless such Gestational Surrogacy Contract see the
Services are Covered Services under this Definitions section of this Benefit Booklet.
Benefit Booklet; and Oral Surgery except as provided under the
10. any Health Care Services rendered by or "What Is Covered?" section.
through a medical or dental department Orthomolecular Therapy including nutrients,
maintained by or on behalf of an employer, vitamins, and food supplements.
mutual association, labor union,trust, or
Oversight of a medical laboratory by a
similar person or group; or
Physician or other health care Provider.
11. Health Care Services that are not direct, "Oversight' as used in this exclusion shall,
hands-on, and patient specific, including, but include, but is not limited to,the oversight of:
not limited to the oversight of a medical
laboratory to assure timeliness, reliability, 1. the laboratory to assure timeliness,
and/or usefulness of test results, or the reliability, and/or usefulness of test results;
oversight of the calibration of laboratory 2. the calibration of laboratory machines or
machines, equipment,or laboratory testing of laboratory equipment;
technicians.
3. the preparation, review or updating of any
Genetic screening, including the evaluation of protocol or procedure created or reviewed
genes to determine if you are a carrier of an by a Physician or other health care Provider
abnormal gene that puts you at risk for a in connection with the operation of the
Condition, except as provided under the laboratory; and
Preventive Adult Wellness Services and
Preventive Child Health Supervision Services 4. laboratory equipment or laboratory
categories of the"What Is Covered?" section. personnel for any reason.
What Is Not Covered? 3-4
Personal Comfort, Hygiene or Convenience Sexual Reassignment,or Modification
Items and Services deemed to be not Medically Services including, but not limited to,any Health
Necessary and not directly related to your Care Services related to such treatment, such
treatment including, but not limited to: as psychiatric Services.
1. beauty and barber services; Smoking Cessation Programs including any
2. clothing including support hose; service to eliminate or reduce the dependency
3. radio and television; on, or addiction to,tobacco, including but not
4. guest meals and accommodations; limited to nicotine withdrawal programs and
nicotine products(e.g.,gum,transdermal
5. telephone charges; patches, etc.).
6. take-home supplies;
7. travel expenses(other than Medically Sports-Related devices and services used to
Necessary Ambulance Services); affect performance primarily in sports-related
activities; all expenses related to physical
8. motel/hotel accommodations; conditioning programs such as athletic training,
9. air conditioners,furnaces, air filters, air or bodybuilding, exercise,fitness,flexibility, and
water purification systems,water softening diversion or general motivation.
systems, humidifiers, dehumidifiers,vacuum
cleaners or any other similar equipment and Training and Educational Programs, or
devices used for environmental control or to materials, including, but not limited to programs
enhance an environmental setting; or materials for pain management and
10. hot tubs, Jacuzzis, heated spas, pools,or vocational rehabilitation, except as provided
memberships to health clubs; under the Diabetes Outpatient Self Management
category of the"What Is Covered?" section.
11. heating pads, hot water bottles, or ice packs;
12. physical fitness equipment; Travel or vacation expenses even if prescribed
13. hand rails and grab bars; and or ordered by a Provider.
14. Massages except as covered in the"What Is Volunteer Services or Services which would
Covered?"section of this Booklet. normally be provided free of charge and any
charges associated with Deductible,
Private Duty Nursing Care rendered at any Coinsurance, or Copayment(if applicable)
location. requirements which are waived by a health care
Rehabilitative Therapies provided on an Provider.
inpatient or outpatient basis, except as provided Weight Control Services including any service
in the Hospital, Skilled Nursing Facility, Home to lose,gain, or maintain weight, including
Health Care, and Outpatient Cardiac, without limitation: any weight control/loss
Occupational, Physical, Speech, Massage program; appetite suppressants; dietary
Therapies and Spinal Manipulations categories regimens;food or food supplements; exercise
of the"What Is Covered?" section. programs; equipment; whether or not it is part of
Rehabilitative Therapies provided for the a treatment plan for a Condition.
purpose of maintaining rather than improving
your Condition are also excluded. Wigs and/or cranial prosthesis.
Reversal of Voluntary, Surgically-Induced
Sterility including the reversal of tubal ligations
and vasectomies.
What Is Not Covered? 3-5
Section 4: Medical Necessity
In order for Health Care Services to be covered 1. staying in the Hospital because
under this Booklet, such Services must meet all 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 in the home, or care in the home, is not
payment under the terms of this Booklet and not
available or inconvenient;or being
for the purpose of recommending or providing hospitalized for any Service which could
medical care. In conducting a review of Medical have been provided adequately in an
Necessity, BCBSF may review specific medical
alternate setting (e.g., Hospital outpatient
facts or information pertaining to you. Any such
department);or
review, however, is strictly for the purpose of
determining whether a Health Care Service 4. inpatient admissions to a Hospital, Skilled
provided or proposed meets the definition of Nursing Facility, or any other facility for the
Medical Necessity in this Booklet. In applying purpose of Custodial Care, convalescent
the definition of Medical Necessity in this care, or any other Service primarily for the
Booklet to a specific Health Care Service, convenience of the patient or his or her
coverage and payment guidelines then in effect family members or a Provider.
may be applied by BCBSF. Note: Whether or not a Health Care Service
All decisions that require or pertain to is specifically listed as an exclusion,the fact
independent professional medical/clinical that a Provider may prescribe, recommend,
judgement or training, or the need for medical approve,or furnish a Health Care Service
services, are solely your responsibility and that does not mean that the Service is Medically
of your treating Physicians and health care Necessary(as defined by this Benefit
Providers. You and your Physicians are Booklet)or a Covered Service. Please refer
responsible for deciding what medical care to the"Definitions" section for the
should be rendered or received and when that definitions of"Medically Necessary" or
care should be provided. Monroe County BOCC "Medical Necessity".
is ultimately responsible for determining whether
expenses incurred for medical care are covered
under this Booklet. In making coverage
decisions, neither BCBSF nor Monroe County
BOCC will be deemed to participate in or
override your decisions concerning your health
or the medical decisions of your health care
Providers.
Examples of hospitalization and other Health
Care Services that are not Medically Necessary
include, but are not limited to:
Medical 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
office Services Copayment applies
Covered Services will be credited toward the regardless of the reason for the office visit
individual Deductible and only up to the and applies to all Covered Services
applicable Allowed Amount. Please see your rendered in the office,with the exception of
Schedule of Benefits for 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
satisfied by you,for each inpatient
information.
admission to a Hospital, Psychiatric Facility,
Copayment Requirements or Substance Abuse Facility, before any
payment will be made for any claim for
Covered Services rendered by certain Providers 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. Coinsurance Requirements
Additionally, you will be responsible for out- All applicable Deductible or Copayment amounts
of-pocket expenses for Covered Services
provided by Physicians and other health must be satisfied before any portion of the
Allowed Amount will be paid for Covered
care professionals for inpatient admissions. Services. For Services that are subject to
Note: Inpatient facility Copayments may Coinsurance,the Coinsurance percentage of the
vary depending on the facility chosen. applicable Allowed Amount you are responsible
(Please see the Schedule of Benefits for for is listed in the Schedule of Benefits.
more information).
3. Outpatient Facility Copayment: Out-of-Pocket Maximums
The outpatient facility Copayment must be Individual out-of-pocket maximum
satisfied by you,for each outpatient visit to a
Hospital, Ambulatory Surgical Center, Once you have reached the individual out-of-
Independent Diagnostic Testing Facility, pocket maximum amount listed in the Schedule
Psychiatric Facility or Substance Abuse of Benefits, you will have no additional out-of-
Facility, before any payment will be made for pocket responsibility for the remainder of that
any claim for outpatient Covered Services. Benefit Period and we will pay 100 percent of
The Outpatient Facility Copayment applies the Allowed Amount for Covered Services
regardless of the reason for the visit, and rendered during the remainder of that Benefit
applies to all outpatient visits to a Hospital, Period.
Psychiatric Facility or Substance Abuse Family out-of-pocket maximum
Facility in or outside the state of Florida.
Additionally, you will be responsible for out- If your plan includes a family out-of-pocket
of-pocket expenses for Covered Services maximum,once your family has reached the
provided by Physician and other healthcare family out-of-pocket maximum amount listed in
professionals. the Schedule of Benefits, neither you nor your
Note: Outpatient facility Copayments may covered family members will have any additional
vary depending on the facility chosen. out-of-pocket responsibility for the remainder of
(Please see the Schedule of Benefits for that Benefit Period and we will pay 100 percent
more information). of the Allowed Amount for Covered Services
rendered during the remainder of that Benefit
4. Emergency Room Facility Copayment: Period. The maximum amount any one Covered
The emergency room facility Copayment Person in your family can contribute toward the
applies regardless of the reason for the visit, family out-of-pocket maximum, if applicable, is
is in addition to the applicable Coinsurance the amount applied toward the individual out-of-
amount, and applies to emergency room pocket maximum. Please see your Schedule of
facility Services in or outside the state of Benefits for more information.
Florida. The emergency room facility Note: The Deductible, any applicable
Copayment must be satisfied by you for
e Copayments and Coinsurance amounts will
each visit. If you are admitted to the
Hospital as an inpatient at the time of the accumulate toward the out-of-pocket maximums.
emergency room visit,the emergency room Any benefit penalty reductions, non-covered
facility Copayment will be waived, but you charges or any charges in excess of the Allowed
will still be responsible for the inpatient Amount will not accumulate toward the out-of-
facility Copayment. pocket maximums. If the Group has purchased
Prescription Drug coverage, any applicable Cost
Understanding Your Share of Health Care Expenses 5-2
Share under the Prescription Drug coverage,will given for Health Care Services which would
not apply to the Deductible or the out-of-pocket have been Covered Services under this
maximums under this Booklet. 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 under the prior group plan,will be applied
Booklet. This provision is only applicable for you toward your benefit maximums under this
during the initial Benefit Period of coverage Booklet.
under this Benefit Booklet and the following
rules apply: Additional Expenses You Must Pay
1. Prior Coverage Credit for Deductible: In addition to your share of the expenses
For the initial Benefit Period of coverage described above, you are also responsible for:
under this Benefit Booklet only,charges 1. any applicable Copayments;
credited towards your Deductible
requirement under the prior policy or plan, 2. expenses incurred for non-covered
for Services rendered during the 90-day Services;
period immediately preceding the Effective 3. charges in excess of any maximum benefit
Date of the coverage under this Benefit limitation listed in the Schedule of Benefits
Booklet,will be credited to the Deductible (e.g.,the Benefit Period maximums);
requirement under this Booklet.
4. charges in excess of the Allowed Amount for
2. Prior Coverage Credit for Coinsurance: Covered Services rendered by Providers
Charges credited by Monroe County who have not agreed to accept the Allowed
BOCC's prior policy or plan,towards your Amount as payment in full;
Coinsurance Maximum,for Services 5. any benefit reductions;
rendered during the 90-day period
immediately preceding the Effective Date of 6. payment of expenses for claims denied
because we did not receive information
coverage under this Benefit Booklet,will be
requested from you regarding whether or not
credited to your out-of-pocket maximum
under this Booklet. you have other coverage and the details of
such coverage; and
3. Prior coverage credit towards the Deductible 7. charges for Health Care Services which are
or out-of-pocket maximums will only be
excluded.
Understanding Your Share of Health Care Expenses 5-3
Additionally, you are responsible for any
contribution amount required by Monroe County
BOCC.
How Benefit Maximums Will Be
Credited
Only amounts actually paid for Covered
Services will be credited towards any applicable
benefit maximums. The amounts paid which are
credited towards your benefit maximums will be
based on the Allowed Amount for the Covered
Services provided.
Understanding Your Share of Health Care Expenses 5-4
Section 6: Physicians, Hospitals and Other Provider
Options
Introduction 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 Location of Service
BlueCard®(Out-of-State)Traditional Program
Providers, in conformity with Section 7: In addition to the participation status of the
BlueCard®(Out-of-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 BlueOptions, 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 6-1
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.bcbsfl.com;and/or
3. If outside of Florida, access the on-line
BlueCard®Doctor and Hospital Finder at
www.bcbs.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 ' You are responsible for filing the
responsible for for you and payment will be claim and payment will be made
filing your made directly to the Provider. directly to the Covered Plan
claims? Participant. If you receive Services
from a Provider who participates in
our Traditional Program or is a
BlueCard®(Out-of-State)Traditional
Program Provider, the Provider will
file the claim for you. In those
instances payment will be made
directly to the Provider.
Can you be billed NO. You are protected from YES. You are responsible for paying
the difference being billed for the difference in the difference between what we pay
between what the the Allowed Amount and the and the Provider's charge. However,
Provider is paid Provider's charge when you use if you receive Services from a
and the Provider's In-Network Providers. The Provider who participates in our
charge? Provider will accept the Allowed Traditional Program,the Provider will
Amount as payment in full for accept our Allowed Amount as
Covered Services except as payment in full for Covered Services
otherwise permitted under the since such Traditional Program
terms of the Provider's contract Providers have agreed not to bill you
and this Booklet. for the difference. Further, under the
BlueCard®(Out-of-State) Program,
when you receive Covered Services
from a BlueCard°(Out-of-State)
Traditional Program Provider, you
may be responsible for paying the
difference between what the Host
Blue pays and the Provider's billed
charge.
Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for
verifying whether that Provider is In-Network or Out-of-Network. You are also responsible for determining
the corresponding payment options, if any, at the time the Health Care Services are rendered.
Physicians,Hospitals and Other Provider Options 6-3
Physicians admits to by contacting the Physician's office.
This will provide you with information that will
When you receive Covered Services from a help you determine a portion of what your out-of-
Physician you will be responsible for a pocket costs may be in the event you are
Copayment and/or the Deductible and the hospitalized.
applicable Coinsurance. Several factors will
Refer to your Schedule of Benefits to determine
determine your out-of-pocket expenses including
the applicable out-of-pocket expenses you are
your Schedule of Benefits,whether the
responsible for paying for Hospital Services.
Physician is In-Network or Out-of-Network,the
location of service, the type of Service rendered, Specialty Pharmacy
and the Physician's specialty.
Certain medications, such as injectable, oral,
Remember that the location or setting where a inhaled and infused therapies used to treat
Service is rendered can affect the amount you complex medical Conditions are typically more
are responsible for paying out-of-pocket. After difficult to maintain, administer and monitor
you and your Physician have determined the when compared to traditional Drugs. Specialty
plan of treatment most appropriate for your care, Drugs may require frequent dosage
you should refer to the Schedule of Benefits and adjustments, special storage and handling and
consult with your Physician to determine the may not be readily available at local pharmacies
most appropriate setting based on your health or routinely stocked by Physicians'offices,
care and financial needs. mostly due to the high cost and complex
Refer to your Schedule of Benefits to determine handling they require.
the applicable Copayments, Coinsurance Using the Specialty Pharmacy to provide these
percentage and/or Deductible amount you are Specialty Drugs should lower the amount you
responsible for paying for Physician Services. have to pay for these medications, while helping
to preserve your benefits.
Hospitals
Other Providers
Each time you receive inpatient or outpatient
Covered Services at a Hospital, in addition to With BlueOptions you have access to other
any out-of-pocket expenses related to Physician Providers in addition to the ones previously
described in this section. Other Providers
Services, you will be responsible for out-of-
pocket expenses related to Hospital Services. include facilities that provide alternative
outpatient settings or other persons and entities
In-Network Hospitals have been divided into two that specialize in a specific Service(s). While
groups that are referred to as"options"on the these Providers may be recognized for payment,
Schedule of Benefits. The amount you are they may not be included as In-Network
responsible for paying out-of-pocket is different Providers for your plan. Additionally, all of the
for each of these options. Remember that there Services that are within the scope of certain
are also different out-of-pocket expenses for Providers' licenses may not be Covered
Out-of-Network Hospitals. Services under this Booklet. Please refer to the
"What Is Covered?" and "What Is Not Covered?"
Since not all Physicians admit patients to every sections of this Booklet and your Schedule of
Hospital, it is important when choosing a Benefits to determine your out-of-pocket
Physician that you determine the Hospitals expenses for Covered Services rendered by
where your Physician has admitting privileges. these Providers.
You can find out what Hospitals your Physician
Physicians,Hospitals and Other Provider Options 6-4
You may be able to receive certain outpatient Hospital, Physician, or dentist and the benefits
Services at a location other than a Hospital. The which have been assigned are for care provided
amount you are responsible for paying for pursuant to section 395.1041, Florida Statutes;
Services rendered at some alternative facilities or 7)is an Ambulance Provider that provides
is generally less than if you had received those transportation for Services from the location
same Services at a Hospital. 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;
4)is a BlueCard®(Out-of-State) PPO Program
Provider; 5) is a BlueCard®(Out-of-State)
Traditional Program Provider;6)is a licensed
Physicians,Hospitals and Other Provider Options 6-5
Section 7: BlueCard® (Out-of-State) Program
Providers Outside the State of paragraph one of this section or require a
Florida surcharge,we will then calculate your liability for
any Covered Services in accordance with the
When you obtain Health Care Services from applicable state statute in effect at the time you
BlueCard°participating Providers outside the received your care.
state of Florida, the amount you pay for
Covered Services is calculated on the lower of:
• The billed charges for your Covered
Services, or
• The negotiated price that the on-site Blue
Cross and/or Blue Shield Plan ("Host Blue")
passes on to us.
Often,this"negotiated price"will consist of a
simple discount,which reflects the actual price
paid by the Host Blue. But sometimes it is an
estimated price that factors into the actual price
expected settlements,withholds, any other
contingent payment arrangements and non-
claims transactions with your health care
Provider or with a specified group of Providers.
The negotiated price may also be billed
charges reduced to reflect an average
expected savings with your health care
Provider or with a specified group of Providers.
The price that reflects average savings may
result in greater variation(more or less)from
the actual price paid than will the estimated
price. The negotiated price will also be
prospectively adjusted in the future to correct
for over-or underestimation of past prices.
However,the amount you pay is considered a
final price.
Statutes in a small number of states may
require the Host Blue to use a basis for
calculating a covered individual's liability for
Covered Services that does not reflect the
entire savings realized, or expected to be
realized, on a particular claim or to add a
surcharge. Should any state statutes mandate
liability calculation methods that differ from the
usual BlueCard®method noted above in
BlueCard(Out-of-State)Program 7-1
Section 8: Blueprint for Health Programs
Introduction Psychiatric Facility, Substance Abuse Facility or
Skilled Nursing Facility(as applicable) if we
BCBSF has established (and from time to time have been notified of your admission. For an
establishes)various customer-focused health admission outside of Florida,you or the
education and information programs as well as
Hospital, Psychiatric Facility, Substance Abuse
benefit utilization management and utilization
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
informed 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 Out-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 available 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 for Health
depending on whether you are admitted to a Programs available to you. You or the Hospital
Hospital, Psychiatric Facility, Substance Abuse may notify BCBSF of your admission by calling
Facility or Skilled Nursing Facility which is In- the toll-free customer service number on your ID
Network or Out-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
discharge, or as part of a review of an episode
comply with our admission notification of care when you are transferred from one level
requirements, you should ask the Hospital,
Blueprint for Health Programs 8-1
of inpatient care to another for ongoing 2. we perform a focused review under the
treatment. The review is conducted solely to focused utilization management program
determine whether we should provide coverage and we determine that a Health Care
and/or payment for a particular admission or Service is not Medically Necessary in
Health Care Services rendered during that accordance with our Medical Necessity
admission. Using our established criteria then in criteria or inconsistent with our benefit
effect,a concurrent review of the inpatient stay guidelines then in effect unless the following
may occur at regular intervals, including in exception applies.
advance of a transfer from one inpatient facility
to another. We will provide notification to your Exception for Certain NetworkBlue Physicians
Physician when inpatient coverage criteria are Certain NetworkBlue Physicians licensed as
no longer met. In administering the inpatient Doctors of Medicine(M.D.)or Doctors of
facility program,we may review specific medical Osteopathy(D.O.)only may bill you for Services
facts or information and assess, among other determined to be not Medically Necessary by
things,the appropriateness of the Services
BCBSF under this focused utilization
being rendered, health care setting and/or the management program if, before you receive the
level of care of an inpatient admission or other
Service:
health care treatment program. Any such
reviews by us, and any reviews or assessments a. they give you a written estimate of your
of specific medical facts or information which we financial obligation for the Service;
conduct, are solely for purposes of making
coverage or payment decisions under this b. they specifically identify the proposed
Benefit Booklet and not for the purpose of Service that BCBSF has determined not to
recommending or providing medical care. be Medically Necessary; and
c. you agree to assume financial responsibility
Provider Focused Utilization for such Service.
Management Program
Certain NetworkBlue Providers have agreed to Prior Coverage Authorization/Pre-
participate in our focused utilization Service Notification Programs
management program. This pre-service review It is important for you to understand our prior
program is intended to promote the efficient coverage authorization programs and how the
delivery of medically appropriate Health Care
Provider you select and the type of Service you
Services by NetworkBlue Providers. Under this
program we may perform focused prospective receive affects these requirements and
reviews of all or specific Health Care Services ultimately how much you are responsible for
proposed for you. In order to perform the paying under this Benefit Booklet.
review,we may require the Provider to submit to You or your Provider will be required to obtain
us specific medical information relating to Health prior coverage authorization from us for:
Care Services proposed for you. These
NetworkBlue Providers have agreed not to bill, 1. certain Prescription Drugs denoted with a
or collect, any payment whatsoever from you or special symbol in the Medication Guide as
us, or any other person or entity, with respect to requiring prior authorization;
a specific Health Care Service if: 2. advanced diagnostic imaging Services,
1. they fail to submit the Health Care Service such as CT scans, MRIs, MRA and nuclear
for a focused prospective review when imaging;
required under the terms of their agreement
with us;or
Blueprint for Health Programs 8-2
3. Autism Spectrum Disorder; Mental not require prior authorization when
Health; and Substance Dependency purchased from an Out-of-Network Provider
Services; and for delivery to you at home.
4. other Health Care Services that are or may For additional details on how to obtain prior
become subject to a prior coverage coverage authorization, and for a list of
authorization program or a pre-service Prescription Drugs that require prior
notification program as defined and coverage authorization, please refer to the
administered by us. Medication Guide.
Prior coverage authorization requirements vary, 2. In the case of advanced diagnostic
depending on whether Services are rendered by imaging Services such as CT scans, MRIs,
an In-Network Provider or an Out-of-Network MRA and nuclear imaging, it is your sole
Provider, as described below: responsibility to comply with our prior
coverage authorization requirements when
In-Network Providers rendered or referred by an Out-of-Network
It is the In-Network Provider's sole responsibility Provider before the advanced diagnostic
to comply with our prior coverage authorization imaging Services are provided. Your
requirements, and therefore you will not be failure to obtain prior coverage
responsible for any benefit reductions if prior authorization will result in denial of
coverage authorization is not obtained before coverage for such Services.
Medically Necessary Services are rendered. For additional details on how to obtain prior
Once we have received the necessary medical coverage authorization for advanced
documentation from the Provider,we will review diagnostic imaging Services, please call the
the information and make a prior coverage customer service phone number on the back
authorization decision, based on our established of your ID Card.
criteria then in effect. The Provider will be 3. In the case of Autism Spectrum Disorder,
notified of the prior coverage authorization Mental Health, and Substance
decision. Dependency Services under a prior
Out-of-Network Providers coverage authorization or pre-service
notification program, it is your sole
1. In the case of Prescription Drugs denoted responsibility to comply with our prior
with a special symbol in the Medication coverage authorization or pre-service
Guide as requiring prior authorization, it is notification requirements when rendered or
your sole responsibility to comply with our referred by an Out-of-Network Provider,
prior coverage authorization requirements before the Services are provided. Failure
when you use an Out-of-Network Provider to obtain prior coverage authorization
before the Prescription Drug is purchased will result in denial of coverage for such
or administered.Your failure to obtain Services.
prior coverage authorization will result in
denial of coverage for such Prescription 4. In the case of other Health Care Services
Drug, including any Service related to the under a prior coverage authorization or pre-
service notification program, it is your sole
Prescription Drug or its administration.
responsibility to comply with our prior
Exception: Self-Administered Prescription coverage authorization or pre-service
Drugs, identified as Specialty Drugs with a notification requirements.when rendered or
special symbol in the Medication Guide, do
Blueprint for Health Programs 8-3
referred by an Out-of-Network Provider, Member Focused Programs
before the Services are provided. Failure
to obtain prior coverage authorization or The Blueprint for Health Programs may include
provide pre-service notification may voluntary programs for certain members. These
result in denial of the claim or application programs may address health promotion,
of a financial penalty assessed at the prevention and early detection of disease,
time the claim is presented for payment chronic illness management programs, case
to us. The penalty applied will be the lesser management programs and other member
of$500 or 20%of the total Allowed Amount focused programs.
of the claim. The decision to apply a penalty Personal Case Management Program
or deny the claim will be made uniformly and
will be identified in the notice describing the The personal case management program
prior coverage authorization and pre-service focuses on members who suffer from a
notification programs. catastrophic illness or injury. In the event you
have a catastrophic or chronic Condition,we
Once the necessary medical documentation has may, in BCBSF's sole discretion, assign a
been received from you and/or the Out-of- Personal Case Manager to you to help
Network Provider, BCBSF or a designated coordinate coverage, benefits, or payment for
vendor,will review the information and make a Health Care Services you receive. Your
prior coverage authorization decision, based on participation in this program is completely
our established criteria then in effect. You will voluntary.
be notified of the prior coverage authorization
Under the personal case management program,
decision. you may be offered alternative benefits or
BCBSF will provide you information for any Out- payment for cost-effective Health Care Services.
of-Network Health Care Service subject to a These alternative benefits or payments may be
prior coverage authorization or pre-service made available on a case-by-case basis when
notification program, including how you can you meet BCBSF's case management criteria
obtain prior coverage authorization and/or then in effect. Such alternative benefits or
provide the pre-service notification for such payments, if any,will be made available in
Service not already listed here. This information accordance with a treatment plan with which
will be provided to you upon enrollment, or at you, or your representative, and your Physician
least 30 days prior to such Out-of-Network agree to in writing. In addition, Monroe County
Services becoming subject to a prior coverage BOCC will be required to specifically agree to
authorization or pre-service notification program. such treatment plan and the alternative benefits
or payment.
See the"Claims Processing" section for
The fact that certain Health Care Services under
information on what you can do if prior coverage
authorization is denied. the personal case management program have
been provided or payment has been made in no
Note: Prior coverage authorization is not way obligates BCBSF, Monroe County BOCC,
required when Covered Services are provided or the Group Health Plan to continue to provide
for the treatment of an Emergency Medical or pay for the same or similar Services. Nothing
Condition. contained in this section shall be deemed a
waiver of Monroe County BOCC's right to
enforce this Booklet in strict accordance with its
terms. The terms of this Booklet will continue to
Blueprint for Health Programs 8-4
apply, except as specifically modified in writing Please note that the Hospital admission
in accordance with the personal case notification requirement and any Blueprint For
management program rules then in effect. Health Program may be discontinued or
Health Information, Promotion, Prevention
modified at any time without notice to you or
and Illness Management Programs your consent.
These Blueprint for Health Programs may
include health information that supports health
care education and choices for healthcare
issues. These programs focus on keeping you
well, help to identify early preventive measures
of treatment and help covered individuals with
chronic problems to enjoy lives that are as
productive and healthy as possible. These
programs may include prenatal educational
programs and illness management programs for
Conditions such as diabetes, cancer and heart
disease. These programs are voluntary and are
designed to enhance your ability to make
informed choices and decisions for your unique
health care needs. You may call the toll free
customer service number on your ID card for
more information. Your participation in this
proaram is completely voluntary.
IMPORTANT INFORMATION RELATING TO
BCBSF'S BLUEPRINT FOR HEALTH
PROGRAMS
All decisions that require or pertain to
independent professional medical/clinical
judgment or training, or the need for medical
services, are solely your responsibility and the
responsibility of your Physicians and other
health care Providers. You and your Physicians
are responsible for deciding what medical care
should be rendered or received, and when and
how that care should be provided. Monroe
County BOCC is ultimately responsible for
determining whether expenses,which have
been or will be incurred for medical care are, or
will be, covered under this Booklet. In fulfilling
this responsibility, neither BCBSF nor Monroe
County BOCC will be deemed to participate in or
override the medical decisions of your health
care Provider.
Blueprint for Health Programs 8-5
Section 9: Pre-existing Conditions Exclusion Period
Introduction 6. Genetic Information in the absence of a
diagnosis of the Condition;
Generally,there is no coverage under this
Booklet for Health Care Services to treat a 7. routine follow-up care of breast cancer after the
Pre-existing Condition, or Conditions arising person was determined to be free of breast
from a Pre-existing Condition, until you have cancer;
been continuously covered under this 8. Conditions arising from domestic violence;or
Booklet for a 12-month period. This 12-
9• inherited diseases of amino acid, organic acid,
month Pre-existing Condition exclusionary
carbohydrate or fat metabolism as well as
period begins on the first day of the Waiting
Period if you are an initial enrollee; or your malabsorption originating from congenital
Effective Date of coverage under the Booklet defects present of birth or acquired during the
if you are a special or annual enrollee. This neonatal period.
exclusionary period also applies to any Genetic Information, as used above, means
prescription drug that is prescribed in information about genes, gene products, and
connection with a Pre-existing Condition. inherited characteristics that may derive from the
This Pre-existing Condition exclusionary individual or a family member. This includes
period does not apply to: information regarding carrier status and information
1. the Covered Employee and each derived from laboratory tests that identify mutations
Covered Dependent who was covered in specific genes or chromosomes, physical medical
under the Group's prior medical plan on examinations,family histories, and direct analysis of
the date immediately preceding the genes or chromosomes.
Effective Date of coverage under this Pre-existing Condition Definition
Booklet;
2. you if you were enrolled during the Initial A Pre-existing Condition means any Condition
related to a physical or mental Condition, regardless
Enrollment Period prior to the Effective of the cause of the Condition,for which medical
Date of the Group; advice, diagnosis, care, or treatment was
3. you when the Group has elected to recommended or received during the six-month
waive, in writing, at the time of Group period immediately preceding:
Application the Pre-existing Conditions 1. the first day of your Waiting Period for initial
exclusionary period for all subsequent enrollees; or
Eligible Employees and/or Eligible 2. your Effective Date of coverage under the
Dependents; Group Health Plan for special and annual
4. any Condition for a Covered Person who enrollees.
is under the age of 19 as of the effective
date of this Benefit Booklet, or if enrolled Reducing the Pre-existing Conditions
thereafter, is under the age of 19 at the Exclusionary Period
time of enrollment; No matter whether you enroll when first eligible or at
5. pregnancy; a later date(such as an Annual Open Enrollment
Period or as a result of Special Enrollment), you
Pre-existing Conditions Exclusion Period 9-1
may be able to reduce or even eliminate the 8. a health plan offered under chapter 89 of Title 5,
Pre-existing Conditions exclusionary period if United States Code;
you have prior Creditable Coverage.
9. a public health plan;
If you are enrolling when you are first eligible
10. a health benefit plan of the Peace Corps;
for coverage and you have no more than a
63 day break in Creditable Coverage as of 11. State Children's Health Insurance Program
your Enrollment Date under this Booklet, (CHIP);
your Pre-existing Conditions exclusionary 12. public health plans established by the federal
period will be reduced by the amount of prior
government;or
Creditable Coverage you have.
1
If, on the other hand, you are enrolling under 3. public health plans established by foreign
this Booklet at any other time as allowed governments.
under its terms, such as during an Annual Proving Creditable Coverage
Open Enrollment Period or a Special
Enrollment Period, your Pre-existing You may provide a Prior/Concurrent Coverage
Conditions exclusionary period will be Affidavit or Certification of Creditable Coverage to
reduced by the amount of any Creditable prove the amount of time you were covered under
Coverage you have; provided there is no Creditable Coverage. Prior health insurers and/or
more than a 63 day break in coverage prior group health plans are required to provide a
to your Enrollment Date in this Booklet. certification of Creditable Coverage to you upon
If you have no Creditable Coverage or none termination of your coverage and at any time upon
that can reduce the Pre-existing Conditions request up to 24 months after termination of your
exclusionary period,the full 12-month Pre- prior health coverage. If you do not provide a
existing Conditions exclusionary period will certification,then you must provide some other
apply. evidence of Creditable Coverage such as a copy of
an ID card or health insurance bill from a prior
Creditable Coverage carrier and attest to the amount of time you were
covered under the Creditable Coverage.
Creditable Coverage is health care coverage
that may include any of the following:
1. a group health insurance plan;
2. individual health insurance;
3. Medicare Part A and Part B;
4. Medicaid;
5. benefits to members and certain former
members of the uniformed services and
their dependents;
6. a medical care program of the Indian
Health Service or of a tribal organization;
7. a State health benefits risk pool;
Pre-existing Conditions Exclusion Period g-Z
Section 10: Eligibility for Coverage
Each employee or other individual who is eligible the 60`h day of continuous service or
to participate in the Monroe County Group Waiting Period.
Health Plan, and who meets and continues to Monroe County BOCC's coverage eligibility
meet the eligibility requirements described in this classifications may be expanded to include:
Booklet, shall be entitled to apply for coverage
under this Booklet. These eligibility 1. retired employees;
requirements are binding upon you and/or your 2. Constitutional Officers and 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 in 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
1. The Covered Employee/Retiree's spouse
following requirements:
under a legally valid existing marriage under
1. The employee must be a bona fide Federal Law.
employee of a Monroe County Employer
participating in the Monroe County Group 2. The Covered Employee/Retiree's natural,
Health Plan; newborn,adopted, Foster, or step child(ren)
(or a child for whom the Covered Employee
2. The employee must be actively working 25 has been court-appointed as legal guardian
hours or more per week on a regular basis; or legal custodian)who has not reached the
3. The employee must have completed the end of the Calendar Year in which he or she
applicable Waiting Period of 60 days of reaches age 26(or in the case of a Foster
continuous service; and Child, is no longer eligible under the Foster
4. The employee must meet any additional Child Program), regardless of the dependent
eligibility requirement(s)required by Monroe child's student or marital status,financial
County BOCC. dependency on the Covered Employee,
whether the dependent child resides with the
Note: Employees and qualified Dependents are Covered Employee, or whether the
eligible for coverage on the day following
Eligibility For Coverage 1 0-1
dependent child is eligible for or enrolled in Handicapped Children
any other group health plan. In the case of a handicapped dependent child,
3. The newborn child of a Covered Dependent such child is eligible to continue coverage as a
child who has not reached the end of the Covered Dependent, beyond the age of 30, if
Calendar Year in which he or she becomes the child is:
26. Coverage for such newborn child will 1. otherwise eligible for coverage under the
automatically terminate 18 months after the Group Health Plan;
birth of the newborn child.
2. incapable of self-sustaining employment by
Note: If a Covered Dependent child who has reason of mental retardation or physical
reached the end of the Calendar Year in which handicap; and
he or she becomes 26 obtains a dependent of
their own (e.g.,through birth or adoption)such 3. chiefly dependent upon the Covered
newborn child will not be eligible for this Employee for support and maintenance
coverage and the Covered Dependent child will provided that the symptoms or causes of the
also lose his or her eligibility for this coverage. It child's handicap existed prior to the child's
is the Covered Employee's sole responsibility to 30th birthday.
establish that a child meets the applicable This eligibility shall terminate on the last day of
requirements for eligibility. the month in 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 as a handicapped child.
reaches age 26. Exception for Students on Medical Leave of
Extension of Eligibility for Dependent Absence from School
Children A Covered Dependent child who is a full-time or
A Covered Dependent child may continue part-time student at an accredited post-
coverage beyond the end of the Calendar Year secondary institution,who takes a physician
in which he or she reaches age 26, provided he certified medically necessary leave of absence
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 a dependent; earlier of 12 months from the first day of the
2. a Florida resident or a full-time or part-time leave of absence or the date the Covered
student; Dependent would otherwise no longer be eligible
for coverage under this Booklet.
3. not enrolled in any other health coverage
policy or group health plan; and
4. not entitled to benefits under Title XVIII of
the Social Security Act unless the child is a
handicapped dependent child.
This eligibility shall terminate on the last day of
the Calendar Year in which the dependent child
reaches age 30.
Eligibility For Coverage 10-2
Section 11 : 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 child(ren)
Neither BCBSF nor Monroe County BOCC will only.
have any obligation whatsoever to any individual Employee/Family Coverage-This type of
who is not properly enrolled. coverage provides coverage for the
Any Employee, Eligible Retiree or Eligible Employee/Retiree and the Covered Dependents.
Dependent who is eligible for coverage under There may be additional contribution amounts
this Booklet may apply for coverage according to for each Covered Dependent based on the
the provisions set forth below. 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
Eligible Retiree is given an opportunity to select
4. complete and submit,through Monroe coverage from among the alternatives included
County BOCC Benefits Office,an in Monroe County BOCC's health benefit
Enrollment Form to add Eligible program. The period is established by Monroe
Dependents. 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 Special Enrollment Period is the 30-day period
available under Monroe County BOCC's of time(unless otherwise noted)immediately
program. Such types may include: 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
subsection.
Employee/Spouse Coverage-This type of
coverage provides coverage for the
Enrollment and Effective Date of Coverage 11-1
Employee Enrollment Enrollment event,during the Special Enrollment
Period.
An Eligible Employee who fails to enroll during Note: For a Covered Dependent child who has
the Initial Enrollment Period will not be covered reached the end of the Calendar Year in which
and may only enroll under this Benefit Booklet he or she becomes 26 and the Covered
during the next Annual Open Enrollment Period Dependent child obtains a dependent of their
established by Monroe County BOCC, or in the own (e.g.,through birth or adoption), such
case of a Special Enrollment event,during the newborn child will not be eligible for this
Special Enrollment Period. The Effective Date coverage and cannot enroll. Further, such
will be the date specified by Monroe County Covered Dependent child will also lose his or
BOCC. her eligibility for this coverage.
Dependent Enrollment Adopted Newborn Child—To enroll an
adopted newborn child,the Covered Plan
An individual may be added upon becoming an Participant must submit an Enrollment Form
Eligible Dependent of a Covered Plan through Monroe County BOCC Benefits Office to
Participant. Below are special rules for certain BCBSF during the 30-day period immediately
Eligible Dependents. following the date of birth. The Effective Date of
coverage for an adopted newborn child, eligible
Newborn Child—To enroll a newborn child who for coverage,will be the moment of birth,
is an Eligible Dependent,the Covered Plan provided that a written agreement to adopt such
Participant must submit an Enrollment Form to child has been entered into by the Covered Plan
BCBSF through Monroe County BOCC Benefits Participant prior to the birth of such child,
Office during the 30-day period immediately whether or not such an agreement is
following the date of birth. The Effective Date of enforceable. The Covered Plan Participant may
coverage for a newborn child will be the date of be required to provide any information and/or
birth. documents that are deemed necessary in order
If timely notice is given, no additional to administer this provision.
contribution will be charged for coverage of the If timely notice is given, no additional
newborn child for not less than 30 days after the contribution will be charged for coverage of the
birth of the child. If timely notice is not received, adopted newborn child for not less than 30 days
the applicable contribution will be charged from after the birth of the child. If timely notice is not
the date of birth. The applicable contribution for received,the applicable contribution will be
the child will be charged after the initial 30-day charged from the date of birth. The applicable
period in either case. Coverage will not be contribution for the child will be charged after the
denied for a newborn child if the Covered Plan initial 30-day period in either case. Coverage
Participant provides notice to Monroe County will not be denied for an adopted newborn child
BOCC Benefits Office and an Enrollment Form if the Covered Plan Participant provides notice
is received within the 60-day period of the birth to Monroe County BOCC Benefits Office and an
of the child and any applicable contribution is Enrollment Form is received within the 60-day
paid back to the date of birth. period of the birth of the adopted newborn child
If the newborn is not enrolled within sixty days of and any applicable contribution is paid back to
the date of birth,the newborn child will not be the date of birth.
covered, and may only be enrolled under this If the adopted newborn child is not enrolled
Benefit Booklet during an Annual Open within sixty days of the date of birth,the adopted
Enrollment Period, or in the case of a Special newborn child will not be covered, and may only
be enrolled under this Benefit Booklet during an
Enrollment and Effective Date of Coverage 11-2
Annual Open Enrollment Period, or in the case responsibility of the Covered Plan Participant to
of a 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,we will
placed in the residence of the Covered Plan terminate the coverage of the child as of the
Participant,there shall be no coverage for the Effective Date of the adopted child upon receipt
adopted newborn child. It is your responsibility of the written notice.
as the Covered Plan Participant to notify Monroe If the Covered Plan Participant's status as a
County BOCC Benefits Office within ten foster parent is terminated, coverage will end for
calendar days of the date that placement was to any Foster Child. It is the responsibility of the
occur if the adopted newborn child is not placed Covered Plan Participant to notify BCBSF
in your residence. through Monroe County BOCC Benefits Office
Adopted/Foster Children—To enroll an that the Foster Child is no longer in the Covered
adopted or Foster Child,the Covered Plan Plan Participant's care. Upon receipt of this
Participant must submit an Enrollment Form notification, coverage for the child will be
during the 30-day period immediately following terminated on the date the Covered Plan
the date of placement. The Effective Date for an Participant's status as a foster parent
adopted or Foster child (other than an adopted terminated.
newborn child)will be the date such adopted or Marital Status—The Covered Plan Participant
Foster child is placed in the residence of the may apply for coverage of an Eligible Dependent
Covered Plan Participant in compliance with due to a 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 in order to Enrollment Form through Monroe County BOCC
properly administer this section. Benefits Office and forward it to BCBSF. The
In the event Monroe County BOCC Benefits Covered Plan Participant must make application
Office is not notified within 30 days of the date of for enrollment within 30 days of the marriage.
placement,the child will be added as of the date The Effective Date of coverage for an Eligible
of placement so long as Covered Plan Dependent who is enrolled as a result of
Participant provides notice to Monroe County marriage is the date of the marriage.
BOCC Benefits Office,and we receive the Court Order—The Covered Plan Participant
Enrollment Form within 60 days of the may apply for coverage for an Eligible
placement. If the adopted or Foster Child is not Dependent outside of the Initial Enrollment
enrolled within sixty days of the date of Period and Annual Open Enrollment Period if a
placement,the adopted or Foster Child will not court has ordered coverage to be 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, or in the case of a Special must complete an 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 of adoption is not Participant must make application for enrollment
issued,coverage shall not be continued for the within 30 days of the court order. The Effective
proposed adopted Child. Proof of final adoption Date of coverage for an Eligible Dependent who
must be submitted to BCBSF through Monroe is enrolled as a result of a court order is the date
County BOCC Benefits Office. It is the required by the court.
Enrollment and Effective Date of Coverage 11-3
Annual Open Enrollment Period health insurance(except in the case of loss
of coverage under a Children's Health
Eligible Employees and/or Eligible Dependents Insurance Program (CHIP)or Medicaid, see
who did not apply for coverage during the Initial #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 the time of initial enrollment provided that:
Open Enrollment Period. The Eligible Employee
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,
in writing,that coverage under a group
The effective date of coverage for an Eligible health plan or health insurance
Employee and any Eligible Dependent(s)will be coverage was the reason for declining
the date established by Monroe County BOCC enrollment;and
Benefits Office.
b) you lost your other coverage under a
Eligible Employees who do not enroll or change group health benefit plan or health
their coverage selection during the Annual Open insurance coverage(except in the case
Enrollment Period, must wait until the next of loss of coverage under a CHIP or
Annual Open Enrollment Period, unless the Medicaid, see#3 below)as a result of
Eligible Employee or the Eligible Dependent is termination of employment, reduction in
enrolled due to a special circumstance as the number of hours you work, reaching
outlined in the Special Enrollment Period or exceeding the maximum lifetime of all
subsection of this section. benefits under other health coverage,
the employer ceased offering group
Special Enrollment Period health coverage, death of your spouse,
divorce, legal separation or employer
An Eligible Employee and/or the Employee's contributions toward such coverage was
Eligible Dependent(s)may apply for coverage terminated; and
outside of the Initial Enrollment Period 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 Note: Loss of coverage for failure to pay
applicable Enrollment Form and forward it to the your required contribution/premium on a
Monroe County BOCC Benefits Office within the 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 Form is 2. If when offered coverage under this plan at
submitted to the Monroe County BOCC Benefits the time of initial eligibility, you stated, in
Office within the indicated time periods: writing,that coverage under a group health
1. If you lose your coverage under another plan or health insurance coverage was the
group health benefit plan (as an employee reason for declining enrollment;and you get
or dependent), or coverage under other married or obtain a dependent through birth,
adoption or placement in anticipation of
Enrollment and Effective Date of Coverage 11-4
adoption and you submit the applicable
Enrollment Form to the Monroe County
BOCC Benefits Office within 30 days of the
date of the event.
or
3. If you or your Eligible Dependent(s)lose
coverage under a CHIP or Medicaid due to
loss of eligibility for such coverage or
become eligible for the optional state
premium assistance program and you
submit the applicable Enrollment Form to
the Monroe County BOCC Benefits Office
within 60 days of the date such coverage
was terminated or the date you become
eligible for the optional state premium
assistance program.
The Effective Date of coverage for you and your
Eligible Dependents added as a result of a
special enrollment event is the date of the
special enrollment event. Eligible Employees or
Eligible Dependents who do not enroll or change
their coverage selection during the Special
Enrollment Period must wait until the next
Annual Open Enrollment Period(See the
Dependent Enrollment subsection of this section
for the rules relating to the enrollment of Eligible
Dependents of a Covered Plan Participant).
Other Provisions Regarding
Enrollment and Effective Date of
Coverage
Individuals who are rehired as employees of
Monroe County BOCC or any of the
Constitutional Officers or their Employees are
considered newly hired employees for purposes
of this section. The provisions of the Group
Health Plan (which includes this Booklet)which
are applicable to newly hired employees and
their Eligible Dependents(e.g., enrollment,
Effective Dates of coverage, Pre-existing
Condition exclusionary period, and Waiting
Period)are applicable to rehired employees and
their Eligible Dependents.
Enrollment and Effective Date of Coverage 11-5
Section 12: 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
Termination of an Individual's
5. on the date specified by Monroe County Coverage for Cause
BOCC that the Covered Plan Participant's
coverage terminates. In the event any of the following occurs, Monroe
County BOCC may terminate an individual's
Termination of a Covered coverage for cause:
Dependent's Coverage
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.
Termination of Coverage 12-1
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).
Tennination of Coverage 12-2
Section 13: 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 a) the Covered Plan Participant's
obligation to notify all Covered Persons of their entitlement to Medicare;
rights under COBRA. If you fail to meet your
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.
d) the employer files bankruptcy(subject to
A summary of your COBRA rights and the bankruptcy court approval); or
general conditions for qualification for COBRA
continuation coverage is provided below. e) a dependent child may elect the 36
month extension if the dependent child
The following is a summary of what you may ceases to be an Eligible Dependent
elect, if COBRA applies to Monroe County under the terms of Monroe County
BOCC and you are eligible for such coverage: 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,
Continuing Coverage Under COBRA 13-1
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.
Continuing Coverage Under COBRA 13-2
Section 14: 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
policy,contract, plan, or program, including
2. your coverage was terminated for any aself-insured plan or program,that provides
reason, including discontinuance of the benefits similar to the benefits provided
Group Health Plan in its entirety and
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 I. 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
non-payment of employee contribution by or partially insured basis,for
Monroe County BOCC, BCBSF must receive benefits similar those provided
the completed converted policy application under this Booklet; or
and the applicable premium payment within III. 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 14-1
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 14-2
Section 15: Extension of Benefits
Extension of Benefits perform those normal day-to-day activities
which you would otherwise perform and you
In the event the Group Health Plan is 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
benefits provisions described below only apply dental treatment as of the termination date
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
in this section do not apply when your coverage provided under this Benefit Booklet if:
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
1. In the event you are totally disabled on the for other than routine examinations,
termination date of the Group Health Plan as prophylaxis,x-rays, sealants, or
a result of a specific Accident or illness orthodontic services; and
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 end 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 15-1
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 15-2
Section 16: 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
Plan is a multi-employer plan, as defined by
Individuals With End Stage Renal 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 16-1
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 16-2
Section 17: Duplication of Coverage Under Other Health
Plans/Programs
Coordination of Benefits with which the law permits coordination of
benefits;
Coordination of Benefits("COB")is a limitation
4. Medicare,as described.in "The Effect of
of coverage and/or benefits to be provided under
this Benefit Booklet. Medicare Coverage/Medicare Secondary
Payer Provisions" section; and
COB determines the manner in which expenses
5. to the extent permitted by law, any other
will be paid when you are covered under more
government sponsored health insurance
than one health plan, program, or policy
program.
providing benefits for Health Care Services.
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 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
BCBSF or another Blue Cross and/or Blue
Health plans, programs or policies which may be
Shield organization has with such Provider. In
subject to COB include, but are not limited to,
the event that the primary payer's payment
the following which will be referred to as
exceeds the Allowed Amount, no payment
"plan(s)"for purposes of this section:
will be made for such Services.
1. any group or non-group health insurance,
The following rules shall be used to establish the
group-type self-insurance, or HMO plan;
order in which 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 other than a dependent,the Group Health
policy and/or medical payment coverage Plan will be secondary.
Duplication of Coverage Under Other Health Plans/Programs 17-1
2. When the Group Health Plan covers a The Group Health Plan will not coordinate
dependent child whose parents are not benefits against an indemnity-type policy, an
separated or divorced: excess insurance policy, a policy with
coverage limited to specified illnesses or
a) the plan of the parent whose birthday, accidents, or a Medicare supplement policy.
excluding year of birth,falls earlier in the
year will be primary; or 6. If you are covered under a COBRA
continuation plan as a result of the purchase
b) if both parents have the same birthday, of coverage as provided under the
excluding year of birth, and the other Consolidated Omnibus Budget
plan has covered one of the parents Reconciliation Act of 1985, as amended,
longer than us,the Group Health Plan and also under another group plan,the
will be secondary. following order of benefits applies:
3. When the Group Health Plan covers a a) first,the plan covering the person as an
dependent child whose parents are employee,or as the employee's
separated or divorced: Dependent; and
a) if the parent with custody is not b) second,the coverage purchased under
remarried,the plan of the parent with the plan covering the person as a former
custody is primary; employee, or as the former employee's
b) if the parent with custody has remarried, Dependent provided according to the
the plan of the parent with custody is provisions of COBRA.
primary;the stepparent's plan is 7. If the other plan does not have rules that
secondary; and the plan of the parent establish the same order of benefits as
without custody pays last; under this Booklet,the benefits under the
c) regardless of which parent has custody, other plan will be determined primary to the
whenever a court decree specifies the benefits under this Booklet.
parent who is financially responsible for
the child's health care expenses,the Coordination of benefits shall not be permitted
plan of that parent is primary. against an indemnity-type policy, an excess
insurance policy as defined in Florida Statutes
4. When the Group Health Plan covers a Section 627.635, a policy with coverage limited
dependent child and the dependent child is to specified illnesses or accidents, or a Medicare
also covered under another plan: supplement policy.
a) the plan of the parent who is neither laid
off nor retired will be primary; or Non-Duplication Of Government
Programs and Worker's
b) if the other plan is not subject to this Compensation
rule, and if, as a result, such plan does
not agree on the order of benefits,this The benefits under this Booklet shall not
paragraph shall not apply. duplicate any benefits to which you or your
5. When rules 1, 2,3, and 4 above do not Covered Dependents are entitled to or eligible
establish an order of benefits,the plan which for under government programs(e.g., Medicare,
has covered you the longest shall be Medicaid,Veterans Administration)or Worker's
primary. Compensation to the extent allowed by law, or
under any extension of benefits of coverage
Duplication of Coverage Under Other Health Plans/Programs 17-2
under a prior plan or program which may be
provided or required by law.
Duplication of Coverage Under Other Health Plans/Programs 17-3
Section 18: 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
Subrogation 18-1
Section 19: Right of Reimbursement
If any payment under this Benefit Booklet is
made to you or on your behalf with respect to
any injury or illness resulting from the intentional
act, negligence, or fault of a third person or
entity, Monroe County BOCC and/or the Group
Health Plan will have a right to be reimbursed by
you (out of any settlement or judgment proceeds
you recover)one dollar($1.00)for each dollar
paid under the terms of the Group Health Plan
minus a pro 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 19-1
Section 20: 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 90
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
applicable procedure code(s);
For purposes of this Benefit Booklet,there are
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 5. the Provider's name and address;
requirements that apply.
6. the name of the individual who received the
Service; and
Claims Processing 20-1
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
ID 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;
Claims Processing 20-2
and 2)Post-Service paper claims within 120 Benefit Determinations on Pre-Service Claims
days of receipt of the completed claim. Claims Involving Urgent Care
processing shall be deemed to have been For a Pre-Service Claim Involving Urgent Care,
completed as of the date the notice of the claims we will use our best efforts to provide notice of
decision is deposited in the mail by us or our determination (whether adverse or not)as
otherwise electronically transmitted. Any claims soon as possible, but not later than 72 hours
payment relating to a Post-Service Claim that is after receipt of the Pre-Service Claim unless
not made by us within the applicable timeframe additional information is required for a coverage
is subject to the payment of simple interest at decision. If additional information is necessary
the rate established by the Florida Insurance to make a determination,we will use our best
Code. efforts to provide notice within 24 hours of: 1)
We will investigate any allegation of improper the need for additional information; 2)the
billing by a Provider upon receipt of written specific information that you or your Provider
notification from you. If we determine that you may need to provide; and 3)the date that we
were billed for a Service that was not actually reasonably expect to provide notice of the
performed, any payment amount will be adjusted decision. If we request additional information,
and, if applicable, a refund will be requested. In we must receive it within 48 hours of our
such a case, if payment to the Provider is request. We will use our best efforts to provide
reduced due solely to the notification from you, notice of the decision on your Pre-Service Claim
we will pay you 20 percent of the amount of the within 48 hours after the earlier of: 1)receipt of
reduction, up to a total of$500. the requested information; or 2)the end of the
period you were afforded to provide the
Pre-Service Claims specified additional information as described
above.
How to File a Pre-Service Claim
Benefit Determinations on Pre-Service Claims
This Benefit Booklet may condition coverage, that Do Not Involve Urgent Care
benefits, or payment(in whole or in part),for a
specific Covered Service, on the receipt by us of We will use our best efforts to provide notice of a
decision on aPre-Service Claim not involving
a Pre-Service Claim as that term is defined
herein. In order to determine whether we must urgent care within 15 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 Is coverage decision. This 15-day determination
Covered?" section and other applicable sections period may be extended by us one time for up to
of this Benefit Booklet. You may also call the an additional 15 days. If such an extension is
customer service number on your ID card for necessary,we will use our best efforts to provide
assistance. notice of the extension and reasons for it. We
will use our best efforts to provide notification of
We are not required to render an opinion or the decision on your Pre-Service claim within a
make a coverage or benefit determination with total of 30 days of the initial receipt of the claim,
respect to a Service that has not actually been if an extension of time was taken by us.
provided to you unless the terms of this Benefit
If additional information is necessary to make a
Booklet require(or condition payment upon)
approval by us for the Service before it is determination,we will use our best efforts to:
received. 1)provide notice of the need for additional
information, prior to the expiration of the initial
15-day period;2)identify the specific information
Claims Processing 20-3
that you or your Provider may need to provide; Requests for Extension of Services
and 3)inform you of the date that we reasonably Your Provider may request an extension of
expect to notify you of our decision. If we coverage or benefits for a Service beyond the
request additional information,we must receive approved period of time or number of approved
it within 45 days of our request for the Services. If the request for an extension is for a
information. We will use our best efforts to Claim Involving Urgent Care,we will use our
provide notification of the decision on your Pre- best efforts to notify you of the approval or denial
Service Claim within 15 days of receipt of the of such requested extension within 24 hours
requested information. after receipt of your request, provided it is
A Pre-Service Claim denial is an Adverse received at least 24 hours prior to the expiration
Benefit Determination and is subject to the of the previously approved number or length of
Adverse Benefit Determination standards and coverage for such Services. We will use our
appeal procedures described in this section. best efforts to notify you within 24 hours if: 1)we
need additional information;or 2)you or your
Concurrent Care Decisions representative failed to follow proper procedures
in your request for an extension. If we request
Reduction or Termination of Coverage or additional information, you will have 48 hours to
Benefits for Services provide the requested information.We may
A reduction or termination of coverage or notify you orally or in writing, unless you or your
benefits for Services will be considered an representative specifically request that it be in
Adverse Benefit Determination when: writing. A denial of a request for extension of
Services is considered an Adverse Benefit
• we have approved in writing coverage or Determination and is subject to the Adverse
benefits for an ongoing course of Services to Benefit Determination review procedure below.
be provided over a period of time or a
number of Services to be rendered; and Standards for Adverse Benefit
Determinations
• the reduction or termination occurs before
the end of such previously approved time or Manner and Content of a Notification of an
number of Services; and Adverse Benefit Determination:
• the reduction or termination of coverage or We will use our best efforts to provide notice of
benefits by us was not due to an any Adverse Benefit Determination in writing.
amendment of this Benefit Booklet or Notification of an Adverse Benefit Determination
termination of your coverage as provided by will include(or will be made available to you free
this Benefit Booklet. of charge upon request):
We will use our best efforts to notify you of such 1. the date the Service or supply was provided;
reduction or termination in advance so that you 2. the Provider's name;
will have a reasonable amount of time to have
the reduction or termination reviewed in 3. the dollar amount of the claim, if applicable;
accordance with the Adverse Benefit 4. the diagnosis codes included on the claim
Determination standards and procedures (e.g., ICD-9, DSM-IV), including a
described below. In no event shall we be description of such codes;
required to provide more than a reasonable 5. the standardized procedure code included
period of time within which you may develop
on the claim (e.g., Current Procedural
your appeal before we actually terminate or Terminology), including a description of such
reduce coverage for the Services. codes;
Claims Processing 20-4
6. the specific reason or reasons for the submitted to us in writing for an internal appeal
Adverse Benefit Determination, including within 365 days of the original Adverse Benefit
any applicable denial code; Determination, except in the case of Concurrent
Care Decisions which may, depending upon the
7. a description of the specific Benefit Booklet
circumstances, require you to file within a
provisions upon which the Adverse Benefit shorter period of time from notice of the denial.
Determination is based, as well as any The following guidelines are applicable to
internal rule, guideline, protocol, or other reviews of Adverse Benefit Determinations:
similar criterion that was relied upon in
making the Adverse Benefit Determination; • We must receive your appeal of an Adverse
Benefit Determination in person or in writing;
8. a description of any additional information
that might change the determination and You may request to review pertinent
why that information is necessary; documents, such as any internal rule,
guideline, protocol,or similar criterion relied
9. a description of the Adverse Benefit upon to make the determination, and submit
Determination review procedures and the issues or comments in writing;
time limits applicable to such procedures; . If the Adverse Benefit Determination is
10. 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
terms of this Benefit Booklet to your medical
determination; and circumstances;
11. You have the right to an independent 0 During the review process, the Services in
external review through an external review question will be reviewed without regard to
organization for certain appeals, as provided the decision reached in the initial
in the Patient Protection and Affordable determination;
Care Act of 2010.
• We may consult with appropriate
If the claim is a Claim Involving Urgent Care,we Physicians, as necessary;
may notify you orally within the proper . Any independent medical consultant who
timeframes, provided we follow-up with a written reviews your Adverse Benefit Determination
or electronic notification meeting the on our behalf will be identified upon request;
requirements of this subsection no later than
three days after the oral notification. • If your claim is a Claim Involving Urgent
Care, you may request an expedited appeal
How to Appeal an Adverse Benefit 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 If you wish to give someone else permission
Determination. An appeal of an Adverse Benefit to appeal an Adverse Benefit Determination
Determination will be reviewed using the review on your behalf,we must receive a
process described below. Your appeal must be completed Appointment of Representative
Claims Processing 20-5
form signed by you indicating the name of will respond to you,within a reasonable time, not
the person who will represent you with to exceed 15 business days.
respect to the appeal. An Appointment of
Representative form is not required if your Requests for an internal appeal should be
Physician is appealing an Adverse Benefit sent to the address below:
Determination relating to a Claim Involving Blue Cross and Blue Shield of Florida, Inc.
Urgent Care. Appointment of Attention: Member Appeals
Representative forms are available at P.O. Box 44197
www.bcbsfl.com or by calling the number on Jacksonville, Florida 32231-4197
the back of your BCBSF ID Card.
Timing of Our Appeal Review on Adverse How to Request External Review of
Benefit Determinations Our Appeal Decision
We will use our best efforts to review your If you are not satisfied with our internal review of
appeal of an Adverse Benefit Determination and your appeal of an Adverse Benefit
communicate the decision in accordance with Determination, please refer to the Adverse
the following time frames: Benefit Determination notice or call the customer
• Pre-Service Claims--within 30 days of the service phone number on your ID Card for
receipt of your appeal;or information on how to request an external
review.
• Post-Service Claims--within 60 days of the
receipt of your appeal;or Additional Claims Processing
Provisions
• Claims Involving Urgent Care(and requests
to extend concurrent care Services made 1. Release of Information/Cooperation:
within 24 hours prior to the termination of the
Services)--within 72 hours of receipt of your In order to process claims,we may need
request. If additional information is certain information, including information
necessary we will notify you within 24 hours regarding other health care coverage you
and we must receive the requested may have. You must cooperate with us in
additional information within 48 hours of our our effort to obtain such information by,
request. After we receive the additional among other ways, signing any release of
information,we will have an additional 48 information form at our request. Failure by
hours to make a final determination. you to fully cooperate with us may result in a
Note:The nature of a claim for Services(i.e. denial of the pending claim and we will have
whether it is"urgent care"or not)is judged as of no liability for such claim.
the time of the benefit determination on review, 2. Physical Examination:
not as of the time the Service was initially
reviewed or provided. In order to make coverage and benefit
decisions,we may, at our expense, require
You, or a Provider acting on your behalf,who you to be examined by a health care
has had a claim denied as not Medically Provider of our choice as often as is
Necessary has the opportunity to appeal the reasonably necessary while a claim is
claim denial.The appeal may be directed to an pending. Failure by you to fully cooperate
employee of BCBSF who is a licensed Physician with such examination shall result in a denial
responsible for Medical Necessity reviews.The of the pending claim and we shall have no
appeal may be by telephone and the Physician liability for such claim.
Claims Processing 20-6
3. Legal Actions: d) A description of the applicable Adverse
No legal action arising out of or in Benefit Determination review
connection with coverage under this Benefit procedures and the time limits
Booklet may be brought against us within applicable to such procedures;and
the 60-day period following our receipt of the e) If the Adverse Benefit Determination is
completed claim as required herein. based on the Medical Necessity or
Additionally, no such action may be brought Experimental or Investigational
after expiration of the applicable statute of limitations and exclusions, a statement
limitations. telling you how you can obtain the
4. Fraud, Misrepresentation or Omission in specific explanation of the scientific or
Applying for Benefits: clinical judgment for the determination.
We rely on the information provided on the 6. Circumstances Beyond Our Control:
itemized statement and the claim form when To the extent that natural disaster,war, riot,
processing a claim. All such information, civil insurrection, epidemic,or other
therefore, must be accurate,truthful and emergency or similar event not within our
complete. Any fraudulent statement, control, results in facilities, personnel or our
omission or concealment of facts, financial resources being unable to process
misrepresentation, or incorrect information claims for Covered Services,we will have no
may result, in addition to any other legal liability or obligation for any delay in the
remedy we may have, in denial of the claim payment of claims for Covered Services,
or cancellation or rescission of your except that we will make a good faith effort
coverage. to make payment for such Services,taking
5. Explanation of Benefits Form: into account the impact of the event. For the
All claims decisions, including denial and purposes of this paragraph, an event is not
claims review decisions,will be within our control if we cannot effectively
communicated to you in writing either on an exercise influence or dominion over its
explanation of benefits form or some other occurrence or non-occurrence.
written correspondence.This form may
indicate:
a) The specific reason or reasons for the
Adverse Benefit Determination;
b) Reference to the specific Benefit
Booklet provisions upon which the
Adverse Benefit Determination is based
as well as any internal rule,guideline,
protocol, or other similar criterion that
was relied upon in making the Adverse
Benefit Determination;
c) A description of any additional
information that would change the initial
determination and why that information
is necessary;
Claims Processing 20-7
Section 21 : 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 will 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 all 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 needed,
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 21-1
Section 22: General Provisions
Access to Information
BCBSF and Monroe County BOCC have the Compliance with State and Federal
right to receive,from you and any health care Laws and Regulations
Provider rendering Services to you, information
that is reasonably necessary, as determined by The terms of coverage and benefits to be
BCBSF and Monroe County BOCC, in order to provided under this Benefit Booklet shall be
administer the coverage and benefits provided, deemed to have been modified and shall be
subject to all applicable confidentiality interpreted, so as to comply with applicable state
requirements listed below. By accepting or federal laws and regulations dealing with
coverage, you authorize every health care benefits, eligibility, enrollment,termination, or
Provider who renders Services to you,to other rights and duties.
disclose to BCBSF and Monroe County BOCC
or to affiliated entities, upon request, all facts, Confidentiality
records, and reports pertaining to your care,
treatment, and physical or mental Condition, and Except as otherwise specifically provided herein;
to permit BCBSF and/or Monroe County BOCC and except as may be required in order for us to
to copy any such records and reports so administer coverage and benefits, specific
obtained. medical information concerning you, received by
Providers, shall be kept confidential by us in
Right to Receive Necessary conformity with applicable law. Such information
Information may be disclosed to third parties for use in
connection with bona fide medical research and
In order to administer coverage and benefits, education, or as reasonably necessary in
BCBSF or Monroe County BOCC may,without connection with the administration of coverage
the consent of, or notice to, any person, plan, or
and benefits, specifically including BCBSF's
organization, obtain from any person, plan, or
quality assurance and Blueprint for Health
organization any information with respect to any
person covered under this Booklet or applicant Programs. Additionally,we may disclose such
for enrollment which BCBSF or Monroe County information to entities affiliated with us or other
BOCC deem to be necessary. persons or entities we utilize to assist in
providing coverage, benefits or services under
Right to Recovery this Booklet. Further, any documents or
information which are properly subpoenaed in a
Whenever the Group Health Plan has made judicial proceeding, or by order of a regulatory
payments in excess of the maximum provided agency, shall not be subject to this provision.
for under this Booklet, BCBSF or Monroe BCBSF's arrangements with a Provider may
County BOCC will have the right to recover any
require that we release certain claims and
such payments,to the extent of such excess,
from you or any person, plan, or other medical information about persons covered
organization that received such payments. under this Booklet to that Provider even if
treatment has not been sought by or through
that Provider. By accepting coverage, you
General Provisions 22-1
hereby authorize us to release to Providers Non-Waiver of Defaults
claims information, including related medical
information, pertaining to you in order for any Any failure by BCBSF or Monroe County BOCC
such Provider to evaluate your financial at any time, or from time to time,to enforce or to
responsibility under this Booklet. require the strict adherence to any of the terms
or conditions described herein,will in no event
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
be deemed given if hand delivered or if mailed
NetworkBlue and the Traditional Provider by United States Mail, postage prepaid, and
Program, and the participation status of addressed as listed below. Such notice will be
individual Providers available through BCBSF, deemed effective as of the date delivered or so
are subject to change at any time by BCBSF deposited in the mail.
without prior notice to you or your approval or
If to BCBSF:
that of Monroe County BOCC. Additionally,
BCBSF may, at any time,terminate or modify To the address printed on the Identification
the terms of any Provider contract and may Card.
enter into additional Provider contracts without If to you:
prior notice to you, or your approval or that of
Monroe County BOCC. It is your responsibility To the latest address provided by you or to
to determine whether a health care Provider is your latest address on Enrollment Forms
an In-Network Provider at the time the Health actually delivered to us.
Care Service is rendered. Under this Booklet, You must notify Monroe County BOCC
your financial responsibility may vary depending Benefits Office immediately of any
upon a Provider's participation status. address change.
Cooperation Required of You and If to Monroe County BOCC:
Your Covered Dependents To the address indicated by Monroe County
BOCC.
You must cooperate with BCBSF and Monroe
County BOCC, and must execute and submit to Our Obligations Upon Termination
us any consents, releases, assignments, and Upon termination of your coverage for any
other documents requested in order to reason,there will be no further liability or
administer, and exercise any rights hereunder. responsibility to you under the Group Health
Failure to do so may result in the denial of Plan, except as specifically described herein.
claims and will constitute grounds for termination
for cause(See the Termination of an Individual's Promissory Estoppel
Coverage for Cause subsection in the No oral statements, representations, or
Termination Of Coverage section). understanding by any person can change,alter,
General Provisions 22-2
delete, add,or otherwise modify the express discontinue or modify any reward program
written terms of this Booklet. features or promotional offers at any time
without your consent.
Florida Agency for Health Care
Administration Performance Data
The performance outcome and financial data
published by the Agency for Health Care
Administration (AHCA), pursuant to Florida
Statute 408.05, or any successor statute,
located at the web site address
www.floridahealthfinder.gov, may be accessed
through the link provided on the Blue Cross and
Blue Shield of Florida corporate web site at
www.bcbsfl.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
General Provisions 22-3
Section 23: Definitions
The following definitions are used in this Benefit 1. In the case of an In-Network Provider
Booklet. Other definitions may be found in the located in 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 of a bodily 2. In the case of an In-Network Provider
infirmity or disease,which results in traumatic 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")
passes on to us,except when the Host Blue
Accidental Dental Injury means an injury to is unable to pass on its negotiated price due
sound natural teeth (not previously to the terms of its Provider contracts. See
compromised by decay)caused by a sudden, the BlueCard°(Out-of-State) Program
unintentional, and unexpected event or force. section for more details.
This term does not include injuries to the mouth, 3. In the case of Out-of-Network Providers
structures within the oral cavity, or injuries to located in Florida who participate in the
natural teeth caused by biting or chewing,
Traditional Program,this amount will be
surgery, or treatment for a disease or illness. established in accordance with the
Administrative Services Only Agreement or applicable agreement between that Provider
ASO Agreement means an agreement between and BCBSF.
Monroe County BOCC and BCBSF. Under the 4. In the case of Out-of-Network Providers
Administrative Services Only Agreement, located outside of Florida who participate in
BCBSF provides claims processing and the BlueCard°(Out-of-State)Traditional
payment services, customer service, utilization Program,this amount will generally be
review services and access to BCBSF's established in accordance with the
NetworkBlue and BCBSF's network of negotiated price that the Host Blue passes
Traditional Insurance Providers. on to us, except when the Host Blue is
Adverse Benefit Determination means any unable to pass on its negotiated price due to
denial, reduction or termination of coverage, the terms of its Provider contracts. See the
benefits, or payment(in whole or in part) under BlueCard (Out-of-State) Program section
the Benefit Booklet with respect to a Pre-Service for more details.
Claim or a Post-Service Claim.Any reduction or 5. In the case of an Out-of-Network Provider
termination of coverage, benefits, or payment in that has not entered into an agreement with
connection with a Concurrent Care Decision, as BCBSF to provide access to a discount from
described in this section, shall also constitute an the billed amount of that Provider for the
Adverse Benefit Determination. specific Covered Services provided to you,
Allowed Amount means the maximum amount the Allowed Amount will be the lesser of that
upon which payment will be based for Covered Provider's actual billed amount for the
Services. The Allowed Amount may be changed specific Covered Services or an amount
at any time without notice to you or your established by BCBSF that may be based
consent. on several factors including (but not
Definitions 1 23-1
necessarily limited to): (i)payment for such billed by such Out-of-Network Provider for such
Services under the Medicare and/or Services. You will be responsible for any
Medicaid programs; (ii)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 in Florida or in other comparable Ambulance means a ground or water vehicle,
market(s),that BCBSF determines are airplane or helicopter properly licensed pursuant
comparable to the Out-of-Network Provider to Chapter 401 of the Florida Statutes,or a
that provided the specific Covered Services similar applicable law in another state.
(which may include payment accepted by Ambulatory Surgical Center means a facility
such Out-of-Network Provider and/or by properly licensed pursuant to Chapter 395 of the
other Providers as participating providers in Florida Statutes, or a similar applicable law of
other provider networks of third-party payers another state,the primary purpose of which is to
which may include,for example, other provide elective surgical care to a patient,
insurance companies and/or health admitted to,and discharged from such facility
maintenance organizations); (iii) payment within the same working day.
amounts which are consistent, as Applied Behavior Analysis means the design,
determined by BCBSF,with BCBSF's implementation and evaluation of environmental
provider network strategies (e.g., does not modifications, using behavioral stimuli and
result in payment that encourages Providers consequences to produce socially significant
participating in a BCBSF network to become improvement in human behavior, including, but
non-participating); and/or, (iv)the cost of not limited to,the use of direct observation,
providing the specific Covered Services. In measurement and functional analysis of the
the case of an Out-of-Network Provider that relations between environment and behavior.
has not entered into an agreement with Artificial Insemination (Al) means a medical
another Blue Cross and/or Blue Shield procedure in which sperm is placed into the
organization to provide access to discounts female reproductive tract by a qualified health
from the billed amount for the specific care provider for the purpose of producing a
Covered Services under the BlueCard (Out- pregnancy.
of-State) Program,the Allowed Amount for Autism Spectrum Disorder means any of the
the specific Covered Services provided to following disorders as defined in the diagnostic
you may be based upon the amount categories of the International Classification of
provided to BCBSF by the other Blue Cross Diseases, Ninth Edition, Clinical Modification
and/or Blue Shield organization where the (ICD-9 CM), or their equivalents in the most
Services were provided at the amount such recently published version of the American
organization would pay non-participating Psychiatric Association's Diagnostic and
Providers in its geographic area for such Statistical Manual of Mental Disorders:
Services. 1. Autistic disorder;
Please specifically note that, in the case of an 2. Asperger's syndrome;
Out-of-Network Provider that has not entered
into an agreement with BCBSF to provide 3. Pervasive developmental disorder not
access to a discount from the billed amount of otherwise specified;and
that Provider,the Allowed Amount for particular 4. Childhood Disintegrative Disorder.
Services is often substantially below the amount
Definitions 23-2
Benefit Period means a consecutive period of BlueCard®(Out-of-State) PPO Program
time, specified by BCBSF and the Group, in Provider means a Provider designated as a
which benefits accumulate toward the BlueCard®(Out-of-State) PPO Program Provider
satisfaction of Deductibles,out-of-pocket by the Host Blue.
maximums and any applicable benefit BlueCard®(Out-of-State)Traditional Program
maximums. Your Benefit Period is listed on your Provider means a Provider designated as a
Schedule of Benefits, and will not be less than BlueCard°(Out-of-State)Traditional Program
12 months unless indicated as such. Provider by the Host Blue.
Birth Center means a facility or institution, other Bone Marrow Transplant means human blood
than a Hospital or Ambulatory Surgical Center, precursor cells administered to a patient to
which is properly licensed pursuant to Chapter restore normal hematological and immunological
383 of the Florida Statutes, or a similar functions following ablative or non-ablative
applicable law of another state, in which births therapy with curative or life-prolonging intent.
are planned to occur away from the mother's Human blood precursor cells may be obtained
usual residence following a normal, from the patient in an autologous transplant, or
uncomplicated, low-risk pregnancy. an allogeneic transplant from a medically
BlueCard®(Out-of-State) Program means a
acceptable related or unrelated donor, and may
be derived from bone marrow,the circulating
national Blue Cross and Blue Shield Association blood, or a combination of bone marrow and
program available through Blue Cross and Blue circulating blood. If chemotherapy is an integral
Shield of Florida, Inc. Subject to any applicable part of the treatment involving bone marrow
BlueCard®(Out-of-State) Program rules and transplantation,the term "Bone Marrow
protocols, you may have access to the Provider Transplant"includes the transplantation as well
discounts of other participating Blue Cross and/or as the administration of chemotherapy and the
Blue Shield plans. See the BlueCard®(Out-of- chemotherapy drugs. The term "Bone Marrow
State)Program section for more details. Transplant"also includes any Services or
® supplies relating to any treatment or therapy
BlueCard (Out-of-State) PPO Program involving the use of high dose or intensive dose
means a national Blue Cross and Blue Shield chemotherapy and human blood precursor cells
Association program available through Blue and includes any and all Hospital, Physician or
Cross and Blue Shield of Florida, Inc. Subject to other health care Provider Health Care Services
any applicable BlueCard®(Out-of-State) which are rendered in order to treat the effects
Program rules and protocols, you may have of, or complications arising from,the use of high
access to the BlueCard®(Out-of-State) PPO dose or intensive dose chemotherapy or human
Program discounts of other participating Blue blood precursor cells(e.g., Hospital room and
Cross and/or Blue Shield plans. board and ancillary Services).
BlueCard°(Out-of-State)Traditional Program Calendar Year begins January 1 st and ends
means a national Blue Cross and Blue Shield December 31st.
Association program available through Blue Cardiac Therapy means Health Care Services
Cross and Blue Shield of Florida, Inc. Subject to any applicable BlueCard®(Out-of-State) provided under the supervision of a Physician,
or an appropriate Provider trained for Cardiac
Program rules and protocols, you may have Therapy,for the purpose of aiding in the
access to the BlueCard®(Out-of-State) restoration of normal heart function in
Traditional Program discounts of other connection with a myocardial infarction,
participating Blue Cross and/or Blue Shield coronary occlusion or coronary bypass surgery.
plans.
Definitions 23-3
Certified Nurse Midwife means a person who or terminate coverage, benefits, or payment
is licensed pursuant to Chapter 464 of the under the personal case management Program
Florida Statutes, or a similar applicable law of as described in the"Blueprint For Health
another state, as an advanced nurse practitioner Programs"section of this Benefit Booklet.
and who is certified to practice midwifery by the
American College of Nurse Midwives. Condition means a disease, illness, ailment,
injury, or pregnancy.
Certified Registered Nurse Anesthetist
means a person who is a properly licensed Convenient Care Center means a properly
nurse who is a certified advanced registered licensed ambulatory center that: 1)treats a
nurse practitioner within the nurse anesthetist limited number of common, low-intensity
category pursuant to Chapter 464 of the Florida illnesses when ready access to the patient's
Statutes, or a similar applicable law of another primary physician is not possible; 2)shares
clinical information about the treatment with the
state.
patient's primary physician; 3) is usually housed
Claim Involving Urgent Care means any in a retail business; and 4)is staffed by at least
request or application for coverage or benefits one master's level nurse(ARNP)who operates
for medical care or treatment that has not yet under a set of clinical protocols that strictly
been provided to you with respect to which the circumscribe the conditions the ARNP can treat.
application of time periods for making non- Although no physician is present at the
urgent care benefit determinations: (1)could Convenient Care Center, medical oversight is
seriously jeopardize your life or health or your based on a written collaborative agreement
ability to regain maximum function; or(2)in the between a supervising physician and the ARNP.
opinion of a Physician with knowledge of your
Condition,would subject you to severe pain that Copayment means the dollar amount
cannot be adequately managed without the established solely by BCBSF and Monroe
proposed Services being rendered. County BOCC which is required to be paid to a
health care Provider by you at the time certain
Coinsurance means your share of health care Covered Services are rendered by that Provider.
expenses for Covered Services. After your
Deductible requirement is met, a percentage of Cost Share means the dollar or percentage
the Allowed Amount will be paid for Covered amount established solely by us,which must be
Services,as listed in the Schedule of Benefits. paid to a health care Provider by you at the time
The percentage you are responsible for is your Covered Services are rendered by that Provider.
Coinsurance. Cost Share may include, but is not limited to
Coinsurance, Copayment, Deductible and/or Per
Concurrent Care Decision means a decision Admission Deductible(PAD)amounts.
by us to deny, reduce, or terminate coverage, Applicable Cost Share amounts are identified in
benefits, or payment(in whole or in part)with your Schedule of Benefits.
respect to a course of treatment to be provided
over a period of time, or a specific number of Covered Dependent means an Eligible
treatments, if we had previously approved or Dependent who meets and continues to meet all
authorized in writing coverage, benefits, or applicable eligibility requirements and who is
p enrolled,and actually covered, under the Group
payment for that course of treatment or number
of treatments. Health Plan other than as a Covered Plan
Participant(See the"Eligibility Requirements for
As defined herein,a Concurrent Care Decision Dependent(s)" subsection of the"Eligibility for
shall not include any decision to deny, reduce, Coverage" section).
Definitions 23-4
Covered Person means a Covered Plan determined by a licensed Physician or
Participant or a Covered Dependent. Psychologist, while keeping the physiological
risk to the individual at a minimum.
Covered Plan Participant means an Eligible
Employee or other individual who meets and Diabetes Educator means a person who is
continues to meet all applicable eligibility properly certified pursuant to Florida law, or a
requirements and who is enrolled, and actually similar applicable law of another state,to
covered, under this Benefit Booklet other than supervise diabetes outpatient self-management
as a Covered Dependent. training and educational services.
Covered Services means those Health Care Dialysis Center means an outpatient facility
Services which meet the criteria listed in the certified by the Centers for Medicare and
"What Is Covered?"section. Medicaid Services(CMMS)and the Florida
Agency for Health Care Administration(or a
Custodial or Custodial Care means care that similar regulatory agency of another state)to
serves to assist an individual in the activities of provide hemodialysis and peritoneal dialysis
daily living, such as assistance in walking,
getting in and out of bed, bathing, dressing, services and support.
feeding,and using the toilet, preparation of Dietitian means a person who is properly
special diets,and supervision of medication that licensed pursuant to Florida law or a similar
usually can be self-administered. Custodial applicable law of another state to provide
Care essentially is personal care that does not nutrition counseling for diabetes outpatient self-
require the continuing attention of trained management services.
medical or paramedical personnel. In
determining whether a person is receiving Durable Medical Equipment means equipment
Custodial Care, consideration is given to the furnished by a supplier or a Home Health
frequency, intensity and level of care and Agency that: 1)can withstand repeated use;
medical supervision required and furnished. A 2)is primarily and customarily used to serve a
determination that care received is Custodial is medical purpose; 3)not for comfort or
not based on the patient's diagnosis,type of convenience; 4)generally is not useful to an
Condition, degree of functional limitation, or individual in the absence of a Condition; and
5)is appropriate for use in the home.
rehabilitation potential.
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.
Definitions 23-5
Eligible Dependent means an individual who Endorsement means an amendment to the
meets and continues to meet all of the eligibility Group Health Plan or this Booklet.
requirements described in the Eligibility
Enrollment Date means the date of enrollment
Requirements for Dependent(s)subsection of
the Eligibility for Coverage section in this Benefit of the individual under the Group Health Plan or,
Booklet, and is eligible to enroll as a Covered if earlier,the first day of the Waiting Period of
Dependent. such enrollment.
Eligible Employee means an active employee Enrollment Forms means those forms,
or retiree who meets and continues to meet all electronic(where available)or paper, which are
of the eligibility requirements described in the used to maintain accurate enrollment files under
Eligibility Requirements for Covered Plan this Benefit Booklet.
Participant subsection of the Eligibility for
Coverage section in the Benefit Booklet and is Experimental or Investigational means any
eligible to enroll as a Covered Plan Participant. evaluation,treatment,therapy, or device which
Any individual who is an Eligible Employee is not involves the application,administration or use, of
a Covered Plan Participant until such individual procedures,techniques,equipment, supplies,
has actually enrolled with, and been accepted products, remedies, vaccines, biological
for coverage as a Covered Plan Participant by products,drugs, pharmaceuticals, or chemical
Monroe County BOCC. compounds if,as determined solely by BCBSF:
Emergency Medical Condition means a 1. such evaluation, treatment,therapy, or
medical or psychiatric Condition or an injury device cannot be lawfully marketed without
manifesting itself by acute symptoms of approval of the United States Food and
sufficient severity(including severe pain)such Drug Administration or the Florida
that a prudent layperson,who possesses an Department of Health and approval for
average knowledge of health and medicine, marketing has not, in fact, been given at the
could reasonably expect the absence of time such is furnished to you; or
immediate medical attention to result in a
condition described in clause(i), (ii), or(iii)of 2. such evaluation,treatment,therapy, or
Section 1867(e)(1)(A)of the Social Security Act. device is provided pursuant to a written
protocol which describes as among its
Emergency Services means,with respect to an objectives the following: determinations of
Emergency Medical Condition: safety,efficacy, or efficacy in comparison to
1. a medical screening examination (as the standard evaluation,treatment,therapy,
required under Section 1867 of the Social or device; or
Security Act)that is within the capability of 3. such evaluation,treatment, therapy, or
the emergency department of a Hospital, device is delivered or should be delivered
including ancillary Services routinely subject to the approval and supervision of
available to the emergency department to an institutional review board or other entity
evaluate such Emergency Medical
Condition; and as required and defined by federal
regulations; or
2. within the capabilities of the staff and
4
facilities available at the hospital, such . credible scientific evidence shows that such
evaluation,treatment,therapy, or device is
further medical examination and treatment
as are required under Section 1867 of such the subject of an ongoing Phase I or II
Act to Stabilize the patient. clinical investigation, or the experimental or
research arm of a Phase III clinical
Definitions 23-6
investigation, or under study to determine: 3. published reports, articles, or other literature
maximum tolerated dosage(s),toxicity, of the United States Department of Health
safety, efficacy, or efficacy as compared and Human Services or the United States
with the standard means for treatment or Public Health Service, including any of the
diagnosis of the Condition in question; or National Institutes of Health, or the United
5. credible scientific evidence shows that the States Office of Technology Assessment;
consensus of opinion among experts is that 4. the written protocol or protocols relied upon
further studies, research, or clinical by the treating Physician or institution or the
investigations are necessary to determine: protocols of another Physician or institution
maximum tolerated dosage(s),toxicity, studying substantially the same evaluation,
safety, efficacy, or efficacy as compared treatment,therapy, or device;
with the standard means for treatment or 5. the written informed consent used by the
diagnosis of the Condition in question; or treating Physician or institution or by another
6. credible scientific evidence shows that such Physician or institution studying substantially
evaluation,treatment,therapy, or device has the same evaluation,treatment,therapy,or
not been proven safe and effective for device;,or
treatment of the Condition in question, as 6. the records(including any reports)of any
evidenced in the most recently published institutional review board of any institution
Medical Literature in the United States, which has reviewed the evaluation,
Canada, or Great Britain, using generally treatment,therapy, or device for the
accepted scientific, medical, or public health Condition in question.
methodologies or statistical practices; or
Note: Health Care Services which are
7. there is no consensus among practicing determined by BCBSF to be Experimental or
Physicians that the treatment,therapy, or Investigational are excluded (see the"What
device is safe and effective for the Condition Is Not Covered?"section). In determining
in question; or
whether a Health Care Service is
8. such evaluation,treatment,therapy, or Experimental or Investigational, BCBSF may
device is not the standard treatment, also rely on the predominant opinion among
therapy, or device utilized by practicing experts, as expressed in the published
Physicians in treating other patients with the authoritative literature,that usage of a
same or similar Condition. particular evaluation,treatment,therapy,or
"Credible scientific evidence"shall mean(as device should be substantially confined to
determined by BCBSF): research settings or that further studies are
necessary in order to define safety,toxicity,
1. records maintained by Physicians or effectiveness, or effectiveness compared
Hospitals rendering care or treatment to you with standard alternatives.
or other patients with the same or similar
Condition; FDA means the United States Food and Drug
Administration.
2. reports, articles, or written assessments in
authoritative medical and scientific literature Foster Child means a person who is placed in
published in the United States, Canada, or your residence and care under the Foster Care
Great Britain; Program by the Florida Department of Health&
Rehabilitative Services in compliance with
Florida Statutes or by a similar regulatory
Definitions 23-7
agency of another state in compliance with that pharmaceuticals, chemical compounds, and
state's applicable laws. other services rendered or supplied, by or at the
Gamete Intrafallopian Transfer(GIFT)means direction of, Providers.
the direct transfer of a mixture of sperm and Home Health Agency means a properly
eggs into the fallopian tube by a qualified health licensed agency or organization which provides
care provider. Fertilization takes place inside health services in the home pursuant to Chapter
the tube. 400 of the Florida Statutes, or a similar
Generally Accepted Standards of Medical applicable law of another state.
Practice means standards that are based on Home Health Care or Home Health Care
credible scientific evidence published in peer- Services means Physician-directed
reviewed medical literature generally recognized professional,technical and related medical and
by the relevant medical community, Physician personal care Services provided on an
Specialty Society recommendations, and the intermittent or part-time basis directly by(or
views of Physicians practicing in relevant clinical indirectly through)a Home Health Agency in
areas and any other relevant factors. your home or residence. For purposes of this
Gestational Surrogate means a woman, definition,a Hospital,Skilled Nursing Facility,
regardless of age,who contracts, orally or in nursing home or other facility will not be
writing,to become pregnant by means of considered an individual's home or residence.
assisted reproductive technology without the use Hospice means a public agency or private
of an egg from her body. organization which is duly licensed by the State
Gestational Surrogacy Contract or of Florida under applicable law, or a similar
Arrangement means an oral or written applicable law of another state,to provide
agreement, regardless of the state or jurisdiction hospice services. In addition, such licensed
where executed, between the Gestational entity must be principally engaged in providing
Surrogate and the intended parent or parents. pain relief, symptom management, and
supportive services to terminally ill persons and
Group means the employer, labor union,trust, their families.
association, partnership, or corporation,
department,other organization or entity through Hospital means a facility properly licensed
which coverage and benefits under this Benefit pursuant to Chapter 395 of the Florida Statutes,
Booklet are made available to you, and through or a similar applicable law of another state,that:
offers services which are more intensive than
which you and your Covered Dependents
become entitled to coverage and benefits for the those required for room, board, personal
Covered Services described herein. services and general nursing care; offers
facilities and beds for use beyond 24 hours; and
Group Health Plan or Group Plan means the regularly makes available at least clinical
plan established and maintained by Monroe laboratory services, diagnostic x-ray services
County BOCC for the provision of health care and treatment facilities for surgery or obstetrical
coverage and benefits to the individuals covered care or other definitive medical treatment of
under this Benefit Booklet. similar extent.
Health Care Services or Services includes The term Hospital does not include: an
treatments,therapies, devices, procedures, Ambulatory Surgical Center; a Skilled Nursing
techniques, equipment, supplies, products, Facility; a stand-alone Birthing Center;a
remedies, vaccines, biological products, drugs, Psychiatric Facility; a Substance Abuse Facility;
Definitions 23-8
a convalescent, rest or nursing home;or a appropriately registered with the Agency for
facility which primarily provides Custodial, Health Care Administration and must comply
educational, or Rehabilitative Therapies. with all applicable Florida law or laws of the
State in which it operates. Further, such an
Note: If services specifically for the entity must meet BCBSF's criteria for eligibility
treatment of a physical disability are as an Independent Diagnostic Testing Facility.
provided in a licensed Hospital which is
accredited by the Joint Commission on the In-Network means,when used in reference to
Accreditation of Health Care Organizations, Covered Services,the level of benefits payable
the American Osteopathic Association, or to an In-Network Provider as designated on the
the Commission on the Accreditation of Schedule of Benefits under the heading "In-
Rehabilitative Facilities, payment for these Network". Otherwise, In-Network means,when
services will not be denied solely because used in reference to a Provider,that, at the time
such Hospital lacks major surgical facilities Covered Services are rendered,the Provider is
and is primarily of a rehabilitative nature. an In-Network Provider under the terms of this
Booklet.
Recognition of these facilities does not
expand the scope of Covered Services. It In-Network Provider means any health care
only expands the setting where Covered Provider who, at the time Covered Services
Services can be performed for coverage were rendered to you, was under contract with
purposes. BCBSF to participate in BCBSF's NetworkBlue
and included in the panel of providers
Identification (ID) Card means the card(s) designated by BCBSF as"In-Network"for your
issued to Covered Plan Participants under the specific plan. (Please refer to your Schedule of
BlueOptions Group Health Plan. The card is not Benefits). For payment purposes under this
transferable to another person. Possession of Benefit Booklet only,the term In-Network
such card in no way guarantees that a particular Provider also refers,when applicable,to any
individual is eligible for, or covered under, this health care Provider located outside the state of
Benefit Booklet. Florida who or which, at the time Health Care
Services were rendered to you, participated as a
Independent Clinical Laboratory means a BlueCard®(Out-of-State) PPO Program Provider
laboratory properly licensed pursuant to Chapter under the Blue Cross Blue Shield Association's
483 of the Florida Statutes, or a similar BlueCard®(Out-of-State) Program.
applicable law of another state,where
examinations are performed on materials or In Vitro Fertilization (IVF) means a process in
specimens taken from the human body to which an egg and sperm are combined in a
provide information or materials used in the laboratory dish to facilitate fertilization. If
diagnosis, prevention, or treatment of a fertilized,the resulting embryo is transferred to
Condition. the woman's uterus.
Independent Diagnostic Testing Facility Licensed Practical Nurse means a person
means a facility, independent of a Hospital or properly licensed to practice practical nursing
Physician's office,which is a fixed location, a pursuant to Chapter 464 of the Florida Statues,
mobile entity, or an individual non-Physician or a similar applicable law of another state.
practitioner where diagnostic tests are Massage Therapist means a person properly
performed by a licensed Physician or by licensed to practice Massage, pursuant to
licensed, certified non-Physician personnel Chapter 480 of the Florida Statutes,or a similar
under appropriate Physician supervision. An applicable law of another state.
Independent Diagnostic Testing Facility must be
Definitions 23-9
Massage or Massage Therapy means the Note: It is important to remember that any
manipulation of superficial tissues of the human review of Medical Necessity by us is solely for
body using the hand,foot, arm, or elbow. For the purpose of determining coverage or benefits
purposes of this Benefit Booklet,the term under this Booklet and not for the purpose of
Massage or Massage Therapy does not include recommending or providing medical care. In this
the application or use of the following or similar respect,we may review specific medical facts or
techniques or items for the purpose of aiding in information pertaining to you. Any such review,
the manipulation of superficial tissues: hot or however, is strictly for the purpose of
cold packs; hydrotherapy; colonic irrigation; determining, among other things,whether a
thermal therapy; chemical or herbal Service provided or proposed meets the
preparations; paraffin baths; infrared light; definition of Medical Necessity in this Booklet as
ultraviolet light; Hubbard tank; or contrast baths. determined by us. In applying the definition of
Mastectomy means the removal of all or part of Medical Necessity in this Booklet,we may apply
the breast for Medically Necessary reasons as our coverage and payment guidelines then in
effect. You are free to obtain a Service even if
determined by a Physician.
we deny coverage because the Service is not
Medical Literature means scientific studies Medically Necessary; however, you will be solely
published in a United States peer-reviewed responsible for paying for the Service.
national professional journal.
Medicare means the federal health insurance
Medical Pharmacy means Physician- provided under Title XVII I of the Social Security
administered Prescription Drugs which are Act and all amendments thereto.
rendered in a Physician's office
Medication Guide for the purpose of this
Medically Necessary or Medical Necessity Benefit Booklet means the guide then in effect
means that,with respect to a Health Care issued by us where you may find information
Service, a Physician, exercising prudent clinical about Specialty Drugs, Prescription Drugs that
judgment, provided the Health Care Service to require prior coverage authorization and Self-
you for the purpose of preventing, evaluating, Administered Prescription Drugs that may be
diagnosing or treating an illness, injury, disease covered under this plan.
or its symptoms, and that the Health Care
Service was: Note: The Medication Guide is subject to
change at any time. Please refer to our website
1. in accordance with Generally Accepted at www.bcbsfl.com for the most current guide or
Standards of Medical Practice; you may call the customer service phone
2. clinically appropriate, in terms of type, number on your Identification Card for current
frequency, extent, site and duration, and information.
considered effective for your illness, injury or Mental Health Professional means a person
disease; and properly licensed to provide mental health
3. not primarily for your convenience,or that of Services, pursuant to Chapter 491 of the Florida
your Physician or other health care Provider, Statutes,or a similar applicable law of another
and not more costly than an alternative state. This professional may be a clinical social
Service or sequence of Services at least as worker, mental health counselor or marriage and
likely to produce equivalent therapeutic or family therapist. A Mental Health Professional
diagnostic results as to the diagnosis or does not include members of any religious
treatment of your illness. denomination who provide counseling services.
Definitions 23-10
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 Diseases, Ninth rendered:
Edition, Clinical Modification (ICD-9 CM),or their 1. did not have a contract with us to participate
equivalents in the most recently published in NetworkBlue but was participating in our
version of the American Psychiatric Traditional Program;or
Association's Diagnostic and Statistical Manual 2. did not have a contract with a Host Blue to
of Mental Disorders, regardless of the underlying participate in its local PPO Program for
cause, or effect, of the disorder. purposes of the BlueCard®(Out-of-State)
Midwife means a person properly licensed to PPO Program but was participating,for
practice midwifery pursuant to Chapter 467 of purposes of the BlueCard®(Out-of-State)
the Florida Statutes, or a similar applicable law Program,as a BlueCard®(Out-of-State)
of another state. Traditional Program Provider; or
NetworkBlue means, or refers to,the preferred 3. did have a contract to participate in
provider network established and so designated NetworkBlue but was not included in the
by BCBSF which is available to individuals panel of Providers designated by us to be
covered under this Benefit Booklet. Please note In-Network for your Plan;or
that BCBSF's Preferred Patient Care(PPC) 4. did not have a contract with us to participate
preferred provider network is not available to in NetworkBlue or our Traditional Program;
individuals covered under this Benefit Booklet. or
5. did not have a contract with a Host Blue to
Occupational Therapist means a person
participate for purposes of the BlueCa
properly licensed to practice Occupational ®
Therapy pursuant to Chapter 468 of the Florida (Out-of-State) Program as a BlueCard
Statutes, or a similar applicable law of another (Out-of State)Traditional Program Provider.
state. Outpatient Rehabilitation Facility means an
entity which renders,through providers properly
Occupational Therapy means a treatment that licensed pursuant to Florida law or the similar
follows an illness or injury and is designed to
help a patient learn to use a newly restored or law or laws of another state: outpatient physical
previously impaired function. therapy; outpatient speech therapy; outpatient
occupational therapy; outpatient cardiac
Orthotic Device means any rigid or semi-rigid rehabilitation therapy; and outpatient Massage
device needed to support a weak or deformed for the primary purpose of restoring or improving
body part or restrict or eliminate body a bodily function impaired or eliminated by a
movement. Condition. Further, such an entity must meet
BCBSF's criteria for eligibility as an Outpatient
Out-of-Network means,when used in reference Rehabilitation Facility. The term Outpatient
to Covered Services,the level of benefits Rehabilitation Facility, as used herein, shall not
payable to an Out-of-Network Provider as include any Hospital including a general acute
designated on the Schedule of Benefits under care Hospital, or any separately organized unit
the heading "Out-of-Network". Otherwise, Out- of a Hospital,which provides comprehensive
of-Network means,when used in reference to a medical rehabilitation inpatient services, or
Provider,that, at the time Covered Services are rehabilitation outpatient services, including, but
rendered,the Provider is not an In-Network not limited to, a Class III "specialty rehabilitation
Provider under the terms of this Booklet. hospital" described in Chapter 59A, Florida
Definitions 23-11
Administrative Code or the similar law or laws of diplomates certified by a board recognized by
another state. the American Board of Medical Specialties.
Pain Management includes, but is not limited Post-Service Claim means any paper or
to, Services for pain assessment, medication, electronic request or application for coverage,
physical therapy, biofeedback,and/or benefits, or payment for a Service actually
counseling. Pain rehabilitation programs are provided to you (not just proposed or
programs featuring multidisciplinary Services recommended)that is received by us on a
directed toward helping those with chronic pain properly completed claim form or electronic
to reduce or limit their pain. format acceptable to us in accordance with the
provisions of this section.
Partial Hospitalization means treatment in
which an individual receives at least seven Pre-Service Claim means any request or
hours of institutional care during a portion of a application for coverage or benefits for a Service
24-hour period and returns home or leaves the that has not yet been provided to you and with
treatment facility during any period in which respect to which the terms of the Benefit Booklet
treatment is not scheduled. A Hospital shall not condition payment for the Service(in whole or in
be considered a"home"for purposes of this part)on approval by us of coverage or benefits
definition. for the Service before you receive it. A Pre-
Service Claim may be a Claim Involving Urgent
Physical Therapy means the treatment of Care. As defined herein, a Pre-Service Claim
disease or injury by physical or mechanical shall not include a request for a decision or
means as defined in Chapter 486 of the Florida opinion by us regarding coverage, benefits, or
Statutes or a similar applicable law of another payment for a Service that has not actually been
state. Such therapy may include traction, active rendered to you if the terms of the Benefit
or passive exercises, or heat therapy. Booklet do not require(or condition payment
Physical Therapist means a person properly upon)approval by us of coverage or benefits for
licensed to practice Physical Therapy pursuant the Service before it is received.
to Chapter 486 of the Florida Statutes, or a Prescription Drug means any medicinal
similar applicable law of another state. substance, remedy, vaccine, biological product,
Physician means any individual who is properly drug, pharmaceutical or chemical compound
licensed by the state of Florida, or a similar which can only be dispensed with a Prescription
applicable law of another state, as a Doctor of and/or which is required by state law to bear the
Medicine(M.D.), Doctor of Osteopathy(D.O.), following statement or similar statement on the
Doctor of Podiatry(D.P.M.), Doctor of label: "Caution: Federal law prohibits
Chiropractic(D.C.), Doctor of Dental Surgery or dispensing without a Prescription".
Dental Medicine(D.D.S. or D.M.D.), or Doctor of Prior/Concurrent Coverage Affidavit means
Optometry(O.D.). the form that an Eligible Employee or Eligible
Physician Assistant means a person properly Dependent can submit to BCBSF as proof of the
licensed pursuant to Chapter 458 of the Florida amount of time the Eligible Employee was
Statutes, or a similar applicable law of another covered under Creditable Coverage.
state. Prosthetist/Orthotist means a person or entity
Physician Specialty Society means a United that is properly licensed, if applicable, under
States medical specialty society that represents Florida law, or a similar applicable law of
another state,to provide services consisting of
Definitions 23-12
the design and fabrication of medical devices eliminated by a Condition, and include, but are
such as braces, splints, and artificial limbs not limited to, Physical Therapy, Speech
prescribed by a Physician. 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 Self-Administered Prescription Drug means
body organ or replaces all or part of the an FDA-approved Prescription Drug that you
functions of a permanently inoperative or may administer to yourself, as recommended by
malfunctioning body part or organ. a Physician.
Provider means any facility, person or entity Skilled Nursing Facility means an institution or
recognized for payment by BCBSF under this part thereof which meets BCBSF's criteria for
Booklet. eligibility as a Skilled Nursing Facility and which:
1)is licensed as a Skilled Nursing Facility by the
Psychiatric Facility means a facility properly state of Florida or a similar applicable law of
licensed under Florida law, or a similar another state; and 2)is accredited as a Skilled
applicable law of another state,to provide for the Nursing Facility by the Joint Commission on
care and treatment of Mental and Nervous Accreditation of Healthcare Organizations or
Disorders. For purposes of this Booklet, a recognized as a Skilled Nursing Facility by the
Psychiatric Facility is not a Hospital or a Secretary of Health and Human Services of the
Substance Abuse Facility, as defined herein. United States under Medicare, unless such
accreditation or recognition requirement has
Psychologist means a person properly licensed been waived by BCBSF.
to practice psychology pursuant to Chapter 490
of the Florida Statutes, or a similar applicable Sound Natural Teeth means teeth that are
law of another state. whole or properly restored (restoration with
amalgams, resin or composite only); are without
Registered Nurse means a person properly impairment, periodontal, or other conditions; and
licensed to practice professional nursing are not in need of Services provided for any
pursuant to Chapter 464 of the Florida Statutes, reason other than an Accidental Dental Injury.
or a similar applicable law of another state: Teeth previously restored with a crown, inlay,
onlay, or porcelain restoration, or treated with
Registered Nurse First Assistant(RNFA) endodontics, are not Sound Natural Teeth.
means a person properly licensed to perform
surgical first assisting services pursuant to Specialty Drug means an FDA-approved
Chapter 464 of the Florida Statutes or a similar Prescription Drug that has been designated,
applicable law of another state. solely by us, as a Specialty Drug due to special
handling, storage,training, distribution
Rehabilitation Services means Services for the requirements and/or management of therapy.
purpose of restoring function lost due to illness, Specialty Drugs may be Provider administered
injury or surgical procedures including but not or self-administered and are identified with a
limited to cardiac rehabilitation, pulmonary special symbol in the Medication Guide.
rehabilitation, Occupational Therapy, Speech
Specialty Pharmacy means a Pharmacy that
Therapy, Physical Therapy and Massage has signed a Participating Pharmacy Provider
Therapy. Agreement with us to provide specific
Rehabilitative Therapies means therapies the Prescription Drug products, as determined by
primary purpose of which is to restore or us. In-Network Specialty Pharmacies are listed
improve bodily or mental functions impaired or in the Medication Guide.
Definitions 23-13
Speech Therapy means the treatment of Traditional Program Providers means, or
speech and language disorders by a Speech refers to,those health care Providers who are
Therapist including language assessment and not NetworkBlue Providers, but who, or which,at
language restorative therapy services. the time you received Services from them were
Stabilize shall have the same meaning with participating in the Traditional Program. For
regard to Emergency Services as the term is purposes of payment under this Benefit Booklet
defined in Section 1867 of the Social Security only,the term Traditional Program Provider also
Act. refers,when applicable,to any health care
Provider located outside the state of Florida who
Speech Therapist means a person properly or which, at the time Health Care Services were
licensed to practice Speech Therapy pursuant to rendered to you, participated as a BlueCard®
Chapter 468 of the Florida Statutes,or a similar Traditional Provider under the Blue Cross and
applicable law of another state. Blue Shield Association's BlueCard®Program.
Traditional providers are considered out of
Standard Reference Compendium means: network for benefit calculation purposes;
1)the United States Pharmacopoeia Drug however, does not balance bill the member.
Information; 2)the American Medical
Association Drug Evaluation; or 3)the American Urgent Care Center means a facility properly
Hospital Formulary Service Hospital Drug licensed that: 1)is available to provide Services
Information. to patients at least 60 hours per week with at
least twenty-five(25)of those available hours
Substance Abuse Facility means a facility after 5:00 p.m. on weekdays or on Saturday or
properly licensed under Florida law, or a similar Sunday; 2) posts instructions for individuals
applicable law of another state,to provide seeking Health Care Services, in a conspicuous
necessary care and treatment for Substance public place, as to where to obtain such
Dependency. For the purposes of this Booklet a Services when the Urgent Care Center is
Substance Abuse Facility is not a Hospital or a
closed; 3)employs or contracts with at least one
Psychiatric Facility, as defined herein. or more Board Certified or Board Eligible
Substance Dependency means a Condition Physicians and Registered Nurses(RNs)who
where a person's alcohol or drug use injures his are physically present during all hours of
or her health; interferes with his or her social or operation. Physicians, RNs, and other medical
economic functioning; or causes the individual to professional staff must have appropriate training
lose self-control. and skills for the care of adults and children; and
4)maintains and operates basic diagnostic
Traditional Program means,or refers to, radiology and laboratory equipment in
BCBSF's provider contracting programs called compliance with applicable state and/or federal
Payment for Physician Services(PPS)and laws and regulations.
Payment for Hospital Services(PHS). For
purposes of this Benefit Booklet,the term For purposes of this Benefit Booklet, an Urgent
Traditional Program also refers,when Care Center is not a Hospital, Psychiatric
applicable, to the traditional Provider contracting Facility, Substance Abuse Facility, Skilled
programs of other Blue Cross and/or Blue Shield Nursing Facility or Outpatient Rehabilitation
organizations as designated under the Blue Facility.
Cross and Blue Shield Association's BlueCard® Waiting Period means the length of time
Program. established by Monroe County BOCC which
must be met by an individual before that
Definitions 23-14
individual becomes eligible for coverage under
this Benefit Booklet.
Zygote Intrafallopian Transfer(ZIFT)means a
process in which an egg is fertilized in the
laboratory and the resulting zygote is transferred
to the fallopian tube at the pronuclear stage
(before cell division takes place). The eggs are
retrieved and fertilized on one day and the
zygote is transferred the following day.
Definitions 23-15
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.
Disclaimer 1
BlueOptions
Schedule of Benefits — Plan 03559
Important things to keep in mind as you review this Schedule of Benefits:
• This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your
benefits can be found.
• NetworkBlue is the panel of Providers designated as In-Network for your plan. You should always
verify a Provider's participation status prior to receiving Health Care Services. To verify a Provider's
specialty or participation status, you may contact the local BCBSF office or access the most recent
BlueOptions Provider directory on our website at www.bcbsfi.com. If you receive Covered Services
outside the state of Florida from BlueCard participating PPO Providers, payment will be made based
on In-Network benefits.
• References to Deductible are abbreviated as"DED".
• Your benefits accumulate toward the satisfaction of Deductibles, Out-of-Pocket Maximums, and any
applicable benefit maximums based on your Benefit Period unless indicated otherwise within this
Schedule of Benefits.
Your Benefit Period.................................................................................................................01/01 —12/31
Deductible, Coinsurance and Out-of-Pocket Maximums
Benefit Description In-Network Out-of-Network
Deductible(DED)
Per Person per Benefit Period $300
Per Family per Benefit Period $600
Per Admission Deductible(PAD) $150 $150
Emergency Room Per Visit Deductible(PVD) $75 $75
Coinsurance
(The percentage of the Allowed Amount you 25% 55%
pay for Covered Services)
Out-of-Pocket Maximums
Per Person per Benefit Period $7,500
Per Family per Benefit Period Not Applicable
BlueOptions ASO
Plan 03559 PC
Amounts incurred for In-Network Services will only be applied to the amounts listed in the In-Network
column and amounts incurred for Out-of-Network Services will only be applied to the amounts listed in
the Out-of-Network column, unless otherwise indicated within this Schedule of Benefits. This includes
the Deductible and Out-of-Pocket Maximum amounts.
What applies to out-of-pocket maximums?
• Coinsurance
• Copayments
What does not apply to out-of-pocket
maximums?
• Non-covered charges
• Any benefit penalty reductions
• Charges in excess of the Allowed Amount
• DIED
• PAD or PVD,when applicable
Important information affecting the amount you will pay:
As you review the Cost Share amounts in the following charts, please remember:
• Review this Schedule of Benefits carefully; it contains important information concerning your share of
the expenses for Covered Services you receive. Amounts listed in this schedule are the Cost Share
amounts you pay.
• Your Cost Share amounts will vary depending upon the Provider you choose,the type of Services
you receive, and the setting in which the Services are rendered.
• Payment for Covered Services is based on our Allowed Amount and may be less than the amount
the Provider bills for such Service. You are responsible for any charges in excess of the Allowed
Amount for Out-of-Network Providers.
• If a Copayment is listed in the charts that follow,the Copayment applies per visit.
BlueOptions ASO
Plan 03559 PC
2
Office Services
A Family Physician is a Physician whose primary specialty is, according to BCBSF's records, one of the
following: Family Practice, General Practice, Internal Medicine, and Pediatrics.
Benefit Description In-Network Out-of-Network
Office visits and Services not otherwise outlined in
this table rendered by:
Family Physicians:
a) Office visit only $20 DED+55%
b) All Services other than office visit DED +25% DED +55%
Other health care professionals licensed to
perform such Services:
a) Office visit only $20 DED+ 55%
b) All Services other than office visit DED +25% DED +55%
Advanced Imaging Services
(CT/CAT Scans, MRAs, MRIs, PET Scans and DED +25% DED +55%
nuclear cardiology)
All other diagnostic Services (e.g.,X-rays) DED +25% DED +55%
Allergy Injections rendered by:
Family Physicians $10 DED +55%
Other health care professionals licensed to °
perform such Services $10 DED +55/o
E-Visits rendered by:
Family Physicians $10 DED+55%
Other health care professionals licensed to °
perform such Services $10 DED + 55/°
Durable Medical Equipment, Prosthetics, and DED +25% DED + 55%
Orthotics
Convenient Care Centers $20 DED + 55%
Chiropractic Services
Note: Includes office and free-standing facilities DED +25% DED +55%
BlueOptions ASO
Plan 03559 PC
3
Preventive Health Services
Benefit Description In-Network Out-of-Network
Adult Wellness Services
Rendered by: °
$0 55%
Family Physicians
Other health care professionals licensed to
perform such Services $0 55%
All other locations $0 55%
Adult Well Woman Services
Rendered by:
Family Physicians $0 55%
Other health care professionals licensed to
perform such Services $0 55%
All other locations $0 55%
Child Health Supervision Services
Rendered by:
Family Physicians $0 55%
Other health care professionals licensed to °
perform such Services $0 55/o
All other locations $0 55%
Mammograms $0 $0
Routine Colonoscopy $0 $0
Outpatient Diagnostic Services
Benefit Description In-Network Out-of-Network
Independent Clinical Lab $0 DED +55%
Independent Diagnostic Testing Facility
Advanced Imaging Services (CT/CAT Scans,
MRAs, MRls, PET Scans and nuclear DED +25% DED +55%
medicine)
All other diagnostic Services(e.g., X-rays) DED +25% DED + 55%
Outpatient Hospital Facility See Hospital Services Outpatient
BlueOptions ASO
Plan 03559 PC
4
Medical Pharmacy
Benefit Description In-Network Out-of-Network
Prescription Drugs administered in the office by:
Family Physicians 20% DED +50%
Physicians other than Family Physicians and 20% DED +50%
other health care professionals licensed to
perform such Services
Out-of-Pocket Maximum per Person per Month $200 Not Applicable
(applies only after DED is satisfied)
Important—The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and
is in addition to the office Services Cost Share. Immunizations, allergy injections as well as Services
covered through a pharmacy program are not considered Medical Pharmacy. Please refer to your
Benefit Booklet for a description of Medical Pharmacy.
Emergency and Urgent Care Services
Benefit Description In-Network Out-of-Network
Ambulance Services DED +25%
Emergency Room Visits See Hospital Services
Emergency Room Visits
Urgent Care Center
a) Office visit only $20 DED +55%
b) All Services other than office visit DED+25% DED +55%
Outpatient Surgical Services
Benefit Description In-Network Out-of-Network
Ambulatory Surgical Center
Facility(per visit) DED +25% DED +55%
Radiologists,Anesthesiologists, and
DED+25% DED +25%
Pathologists
Other health care professional Services
DED +25% DED+ 55%
rendered by all other Providers
Outpatient Hospital Facility See Hospital Services
Outpatient
BlueOptions ASO
Plan 03559 PC
5
Hospital Services
In-Network
Option 1* Option 2* Out-of-Network and
Benefit Description and Out-of-State Traditional
BlueCard Providers
Participating PPO
Providers
Inpatient
$150 PAD + DED+25% $150 PAD + DED +
Facility Services ( per admission) 55%
Physician and other health care DED +25% DED +25%
professional Services
Outpatient
Facility(per visit) DED +25% DED+55%
Physician and other health care DED +25% DED+25%
professional Services
Therapy Services DED +25% DED +55%
Emergency Room Visits
Facility $75 PVD+ DED+25% $75 PVD + DED +
25%
Physician and other health care DED +25% DED +25%
professional Services
Important:
Certain categories of Providers may not be available In-Network in all geographic regions. This includes,
but is not limited to, anesthesiologists, radiologists, pathologists and emergency room physicians. We will
pay for Covered Services rendered by a Physician in a Hospital setting (i.e., inpatient, outpatient, or
emergency room)at the In-Network benefit level. If such Covered Services were rendered by a Physician
who is not In-Network, or a Physician who is not participating in our Traditional Program, you will be
responsible for the difference between what we pay and the Physician's charge. Claims paid in
accordance with this note will be applied to the In-Network DED and Out-of-Pocket Maximums.
*Please refer to the current Provider Directory to determine the applicable option for each In-Network
Hospital.
BlueOptions ASO
Plan 03559 PC
6
Behavioral Health Services
Benefit Description In-Network Out-of-Network
Mental Health and Substance Dependency Care
and Treatment Services
Outpatient Facility Services rendered at:
Emergency Room $75 PVD + DED +25% $75 PVD+ DED+25%
Hospital DED+25% DED +55%
Physician Services at Hospital and ER DED +25% DED +25%
Physician and other health care professionals
licensed to perform such Services
Family Physician office:
a) Office visit only $20 DED +55%
b) All Services other than office visit DED +25% DED +55%
Specialist office:
a) Office visit only $20 DED+55%
b) All Services other than office visit DED +25% DED+ 55%
All other locations DED +25% DED +55%
Inpatient
Facility Services $150 PAD+ DED +25% $150 PAD +DED + 55%
Physician and other health care professionals DED +25% DED +25%
licensed to perform such Services
BlueOptions ASO
Plan 03559 PC
7
Benefit Maximums
Ambulance Services Per day for ground, air and water travel..........................................................$5,000
Note: In addition to the Cost Share listed in this Schedule of Benefits you are responsible for any
additional amounts that exceed the per day maximum.
Autism Spectrum Disorder Services
PerBenefit Period.........................................................................................................................Unlimited
PerLifetime...................................................................................................................................Unlimited
Enteral Formula per Benefit Period....................................................................................................$2,500
Home Health Care Visits per Benefit Period..............................................................................................40
Inpatient Rehabilitation days per Benefit Period......................................................................................21
Outpatient Therapies and Spinal Manipulations Visits per Benefit Period............................................50
Note: Spinal Manipulations are limited to 26 visits per Benefit Period and accumulate towards the
Outpatient Therapies and Spinal Manipulations benefit maximum. Refer to the Benefit Booklet for
reimbursement guidelines.
Preventive Adult Wellness per Benefit Period..............................................................................Unlimited
Skilled Nursing Facility days per Benefit Period...........................................................................Unlimited
Total Lifetime Maximum Benefit...................................................................................................Unlimited
Additional Benefits/Features
Benefit Maximum Carryover
If, immediately before the Effective Date of the Group,you or your Covered Dependent were covered
under a prior group policy form issued by BCBSF or Health Options, Inc.to the Group, amounts applied
to your Benefit Period maximums and Lifetime maximums under the prior BCBSF or Health Options, Inc.
policy will be applied toward your Benefit Period maximums and Lifetime maximums under this plan.
BlueOptions ASO
Plan 03559 PC
8
Supplement to the
BlueOptions
Benefit Booklet for Covered Plan
Participants of Monroe County
BOCC Group Health Plan
Effective as of January 1, 2013
This is a supplement to the Blue Options Benefit Booklet ("Booklet") and is intended to provide
information not otherwise included in the Booklet. In the event of a conflict between this
Supplement and the Booklet, the provisions of this Supplement shall govern. In the event of a
conflict between this Supplement and a County Resolution, the County Resolution shall govern.
1
Table of Contents
DEFINITIONS................................................................................................................................ 3
Eligible Domestic Partner........................................................................................................... 3
EligibleRetiree........................................................................................................................... 6
ELIGIBILITY FOR COVERAGE—RETIREES AND DOMESTIC PARTNERS...................... 7
EligibleRetirees.......................................................................................................................... 7
DomesticPartners....................................................................................................................... 7
PRESCRIPTIONCOVERAGE...................................................................................................... 7
OPTOUT........................................................................................................................................ 8
InitialEnrollment Period............................................................................................................. 8
OpenEnrollment Period ............................................................................................................. 8
CESSATIONOF ACTIVE WORK................................................................................................ 8
ApprovedMedical Leave............................................................................................................ 8
Rehire/Reinstatement.................................................................................................................. 9
ActiveMilitary Duty................................................................................................................... 9
CONTINUATION OF COVERAGE............................................................................................. 9
Surviving Spouses of Covered Retirees......................................................................................
DomesticPartners....................................................................................................................... 9
General Notice of COBRA Continuation Coverage Rights ....................................................... 9
What is COBRA Continuation Coverage? ................................................................................... 10
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN'S HEALTH
INSURANCEPROGRAM (CHIP).............................................................................................. 13
CARRIERS AND CONTACT INFORMATION FOR NON-MEDICAL BENEFITS............... 16
2
DEFINITIONS
Eligible Domestic Partner means an individual who meets the requirements of Resolution
No. 081-1998 as restated below:
14.02 DEFINITIONS
A. Domestic Partners. "Domestic Partners"are two adults who have chosen to share
one another's lives in a committed family relationship of mutual caring. Two
individuals are considered to be Domestic Partners if:
1. they consider themselves to be members of each others immediate family;
2. they agree to be jointly responsible for each other's basic living expenses;
3. neither of them is married or a member of another Domestic Partnership;
4. they are not blood related in a way that would prevent them from being
married to each other under the laws of Florida;
5. each is at least of the legal age and competency required by Florida law to
enter into a marriage or other binding contract;
6. they must each sign a Declaration of Domestic Partnership as provided for
in Section 14.03 of Monroe County BOCC's Personnel Policies and Procedures
Manual;
7. they both reside at the same address.
B. Joint Responsibility for Basic Living Expenses. "Basic living expenses" means
basic food and shelter. "Joint responsibility" means that each partner agrees to
provide for the other's basic living expenses while the domestic partnership is in
effect if the partner is unable to provide for him or herself. It does not mean that
the partners must contribute equally or jointly to basic living expenses.
C. Competent to Contract. "Competent to Contract" means the two partners are
mentally competent to contract.
D. Domestic Partnership. "Domestic Partnership" means the entity formed by two
individuals who have met the criteria listed above and file a Declaration of
Domestic Partnership as described below.
E. Declaration of Domestic Partnership. "Declaration of Domestic Partnership"or
"DDP"is a form provided by the Human Resources Director. By signing it, two
people swear under penalty of perjury that they meet the requirements of the
definition of domestic partnership when they sign the statement. The form shall
require each partner to provide a mailing address.
F. Dependent. "Dependent" means an individual who lives within the household of
a domestic partnership and is:
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1. A biological child or adopted child of a domestic partner; or
2. A dependent as defined under County employee benefit plan document.
3. A ward of a domestic partner as determined in a guardianship proceeding.
G. Employee means an employee of the Board of County Commissioners, the
constitutional officers or the Mosquito Control Board, except where the context is
otherwise.
14.03 ESTABLISHING A DOMESTIC PARTNERSHIP
A. An employee and his/her domestic partner as set out in Section 14.02 are eligible
to declare a Declaration of Domestic Partnership (hereafter DPP) in the presence
of the Human Resources Director, or the employee partner may present a signed
and notarized DDP to the Human Resources Director. The DDP shall include the
name and date of birth of each of the domestic partners, the address of their
common household, and the names and dates of birth of any dependents of the
domestic partnership, and shall be signed,under the pain and penalties of perjury,
by both domestic partners and witnessed(two) and notarized.
B. As further evidence of two individuals being involved in a domestic partnership,
two of the following documents must be presented along with the DDP to the
Human Resources Director:
1. A lease, deed or mortgage indicating that both parties are joint
responsible;
2. Driver's licenses for both partners showing same address;
3. Passports for both partners showing the same address;
4. Verification of a joint bank account(savings or checking)
5. Credit cards with the same account numbers in both names;
6. Joint wills;
7. Powers of attorney; or
8. Joint title indicating both partners own a vehicle.
C. An individual cannot become a member of a domestic partnership until at least six
months after any other domestic partnership of which she or he was a member has
ended and a notice that the partnership has ended was given as provided for in
Section 14.04. This does not apply if their domestic partners are deceased.
D. Domestic partners may amend the DDP to add or delete dependents or change the
household address. Amendments to the DDP shall be executed in the same
manner as the declaration of a domestic partnership.
14.04 TERMINATION OF A DOMESTIC PARTNERSHIP
A. A domestic partnership is terminated when:
1. one of the partners dies;
2. one of the partners marries; or
3. a domestic partner files a termination statement with the Human
Resources Director. A domestic partnership may be terminated by a domestic
partner who files with the Human Resources Director by hand or by certified
4
mail, a termination statement. The person filing the termination statement must
declare under pain and penalties of perjury that the domestic partnership is
terminated and that a copy of the termination statement has been mailed by
certified mail to the other domestic partner at his or her last known address. The
person filing the termination statement must include on such statement the
address to which the copy was mailed.
B. The termination of a domestic partnership shall be effective immediately upon the
date of a domestic partner. The voluntary termination of a domestic partnership
by a partner shall be effective thirty(30) days after the receipt of a termination
statement by the Human Resources Director. If the termination statement is
withdraw before the effective date, the domestic partner shall give notice of the
withdrawal,by certified mail, to the other domestic partner.
C. If a domestic partnership is terminated by the death of a domestic partner, there
shall be no required waiting period prior to filing another domestic partnership. If
a domestic partnership is terminated by one or both domestic partners, neither
domestic partner may file another domestic partnership until six(6) months have
elapsed from effective termination.
D. It is the obligation of the employee domestic partner to notify the Human
Resources Director of the termination of a domestic partnership as soon as
possible after it occurs.
14.05 HUMAN RESOURCES DIRECTOR RECORDS
A. The Human Resources Director will keep a record of all employees DDP's,
Amendments and Termination Statements. The records will be maintained so that
DDPs, Amendments and Termination Statements will be filed to which they
apply.
B. The Human Resources Director shall indentify on the DDP what type of
documents was presented for further verification of the domestic partnership.
C. Upon determination by the Human Resources Director that the DDP is complete
and that further evidence of the domestic partnership has been presented as
provided in Section 14.03(B); the Human Resources Director shall provide the
employee with a copy of the DDP. The employee/domestic partner shall become
eligible to elect domestic partnership health and other employee fringe benefits as
provided in Section 14.06. It will be the employee's responsibility to notify the
Employee Benefits Section of their intent to enroll the domestic partner and/or
any eligible dependents under the Monroe County Employee Benefit Plan.
Domestic partner/dependents enrolled in the Monroe County Employee Benefit
Plan are subject to the same rules and provision applicable to covered
spouses/dependents.
D. The Human Resources Director shall provide forms to employees requesting
them.
E. The Human Resources Director shall allow public access to domestic partnership
records to the same extend and in the same manner as any other public record.
5
Eligible Retiree means an individual who meets one of the following requirements as
established by the Board of County Commissioners Resolution No. 354-2003 —Retirement
Eligibility Requirements for Group Health Insurance Coverage for Monroe County Employees:
• Hire date prior to 10/01/01; a minimum of ten(10) years of full-time service with
Monroe County; retire under the FRS on, or after, the Normal Retirement date as
described in Section 121.021(29), F.S.; and covered under the Plan at retirement. Current
contribution is HIS* for 10 years of service with FRS.
• Hire date prior to 10/01/01; a minimum of ten(10) years of full-time service with
Monroe County; retire under the FRS at an Early Retirement date as described in Section
121.021(30), F.S.; covered under the Plan at retirement; 60 years of age or age and years
of service must satisfy Rule of 70** at time of retirement. Current contribution is HIS*
for 10 years of service with FRS.
• Hire date prior to 10/01/01; a minimum of ten(10) years of full-time service with
Monroe County; retire under the FRS at an Early Retirement date as described in Section
121.021(30), F.S.; covered under the Plan upon retirement;NOT 60 years of age and age
and years of service do not satisfy Rule of 70**. Current contribution is the departmental
rate. Upon attaining either the age of 60 or satisfy Rule of 70** the contribution will
change to the HIS* for 10 years of service with FRS.
• Hire date on or after 10/01/01; a minimum of ten(10) years of full-time service with
Monroe County; retire with the FRS as described in Section 121.021(29 or 121.021 (30),
F.S.; covered under the Plan upon retirement. Current contribution is departmental rate.
• Retire from FRS as described in Section 121.021(29) or 121.021(30), F.S.; less than ten
(10) years of full-time service with Monroe County; covered under the Plan upon
retirement. Current contribution is the departmental rate.
• Former Eligible Employee with at least ten(10) years of full-time service with Monroe
County; covered under the Plan upon termination of employment and fully vested under
FRS who elect not to retire under FRS upon termination of employment with Monroe
County, may elect to re-enroll under the Plan upon retirement under FRS, provided that
Monroe County was their last FRS employer. Current contribution is the departmental
rate.
*HIS: Health Insurance Subsidy per Section 112.363, Florida Statutes.
**Rule of 70: Eligible Retirees satisfy the Rule of 70 if their age, combined with the number of
years of service with Monroe County, totals 70 or more.
6
ELIGIBILITY FOR COVERAGE—RETIREES AND DOMESTIC PARTNERS
Eligible Retirees
An individual who meets the eligibility criteria specified below is an Eligible Retiree and is
eligible to apply for coverage under this Booklet:
A person who elects to continue or re-enroll in the Monroe County Group Health Plan at
the time of their official retirement under the Florida Retirement System (FRS), and if not
currently an Eligible Employee, Monroe County was their last FRS employer prior to
retirement. If the Eligible Retiree fails to elect retiree coverage at time of retirement,
waives retiree coverage or lets coverage lapse, the Eligible Retiree will permanently lose
entitlement to enroll under the Monroe County Group Health Plan.
Domestic Partners
An individual who is an Eligible Domestic Partner or the dependent child of an Eligible
Domestic Partner is eligible to apply for coverage under this Booklet as an Eligible Dependent.
PRESCRIPTION COVERAGE
30 day Retail
Generic (Tier 1) $10
Formulary Brand(Tier 2) $25
Non-Formulary Brand(Tier 3) $70
90 Day Retail
Generic (Tier 1) $25
Formulary Brand (Tier 2) $62.50
Non-Formulary Brand(Tier 3) $175
90 Day Mail Order
Generic (Tier 1) $25
Formulary Brand (Tier 2) $62.50
Non-Formulary Brand(Tier 3) $175
7
OPT OUT
Initial Enrollinent Period means the 30 day period starting on your date of hire during
which you and your eligible dependent(s)have the ability to either elect coverage for yourself
and/or your eligible dependents, or Opt Out of coverage. You can Opt Out by indicating that
you elect to waive coverage on the Monroe County Benefits Enrollment Form. If you Opt Out
during your Initial Enrollment Period, you will not be able to enroll in the Monroe County Group
Health Plan unless you have a Special Enrollment right or during a future Open Enrollment
Period.
Open Enrollment Period means the period selected by Monroe County during which you
can elect coverage for yourself and/or your eligible dependents, or Opt Out of coverage, for the
immediately following Plan Year. You can Opt Out by indicating that you elect to waive
coverage on the Monroe County Benefits Enrollment Form. If you Opt Out during the Open
Enrollment Period, you will not be able to enroll in the Monroe County Group Health Plan
unless you have a Special Enrollment right or during a future Open Enrollment Period.
CESSATION OF ACTIVE WORK
Approved Medical Leave
If an Eligible Employee ceases Active Work due to illness, injury or pregnancy the Employer in
its sole discretion may approve a medical leave of absence. Coverage for the Eligible Employee
will continue under the Plan, but for no longer than six (6) months from the date the approved
medical leave begins. Coverage of Eligible Dependents will continue during this time provided
required premiums are continued to be paid. Notification of all approved medical leave must be
provided to the Monroe County Group Health Plan Administrator(Benefits Office)by the
Employer. The notification should contain the date on which the leave began and when it will
end. An Eligible Employee who has been on an approved medical leave must return to active
work for a minimum of 30 days after the approved medical leave ends. In the event an Eligible
Employee on an approved medical leave does not return to active work at the end of the leave,
the Eligible Employee will be required to reimburse the Plan for the health benefit premiums
paid during the leave to continue coverage.
Note: When an Eligible Employee fails to return to active work because of the continuation,
recurrence, or onset of either a serious health condition of the Eligible Employee or an Eligible
Employee's family member the Plan will not recover the health benefit premium payments made
on the Eligible Employee's behalf during the approved medical leave. The Monroe County
Group Health Plan Administrator(Benefits Office) may require medical certification of the
Eligible Employee's or the Eligible Employee's family member's serious health condition.
8
Rehire/Reinstatement
If subsequent to termination of coverage an Eligible Employee is rehired or reinstated as an
Eligible Employee the Eligible Employee must meet the eligibility requirements in the Eligibility
for Coverage section. However, the Plan allows a grace period of 2 days following the date of
termination of coverage during which an Eligible Employee may be rehired or reinstated without
penalty.
Active Military Duty
Return from active military duty by a former Eligible Employee of two weeks or longer who is
rehired or reinstated will be treated as if the Eligible Employee were on an approved leave of
absence for purposes of eligibility under the Plan. The Plan's waiting period or preexisting
condition exclusion period will not be applicable.
CONTINUATION OF COVERAGE
Surviving Spouses of Covered Retirees: Upon the death of a Covered Retiree, the
Surviving Spouse may continue coverage under the Monroe County Group Health Plan
provided: (1) the Surviving Spouse does not remarry; and (2) the Surving Spouse makes timely
payment of any required contribution. It is the sole responsibility of the Surviving Spouse to
notify the Monroe County Group Health Plan Administrator(Employee Benefits Office) of a
change in marital status.
Domestic Partners: For purposes of COBRA Continuation Coverage Rights, a Domestic
Partner of an Eligible Employee shall be treated as the Eligible Employee's"spouse"and the
dependent child(ren) of a Domestic Partner shall be treated as the Eligible Employee's
stepchild(ren).
General Notice of COBRA Continuation Coverage Rights
Introduction
You are receiving this notice because you are or have recently become covered under a group
health plan (the Plan). This notice contains important information about your right to COBRA
continuation coverage, which is a temporary extension of coverage under the Plan. This notice
generally explains COBRA continuation coverage,when it may become available to you
and your family, and what you need to do to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can
become available to you when you would otherwise lose your group health coverage. It can also
become available to other members of your family who are covered under the Plan when they
would otherwise lose their group health coverage. For additional information about your rights
and obligations under the Plan and under federal law, you should review the Plan's Benefit
9
Booklet or contact the County's Employee Benefits Department.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would
otherwise end because of a life event known as a"qualifying event." Specific qualifying events
are listed later in this notice. After a qualifying event, COBRA continuation coverage must be
offered to each person who is a"qualified beneficiary." You, your spouse, and your dependent
children could become qualified beneficiaries if coverage under the Plan is lost because of the
qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation
coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under
the Plan because either one of the following qualifying events happens:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your
coverage under the Plan because any of the following qualifying events happens:
• Your spouse dies;
• Your spouse's hours of employment are reduced;
• Your spouse's employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the
Plan because any of the following qualifying events happens:
• The parent-employee dies;
• The parent-employee's hours of employment are reduced;
• The parent-employee's employment ends for any reason other than his or her gross
misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the plan as a"dependent child."
-----------------------------------------------------------------------------------------,
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be
a qualifying event. If a proceeding in bankruptcy is filed on behalf of the Monroe County
Board of County Commissioners, and that bankruptcy results in the loss of coverage of any
retired employee covered under the Plan, the retired employee will become a qualified
beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse,
and dependent children will also become qualified beneficiaries if bankruptcy results in the
loss of their coverage under the Plan.
---------------------------------------------------------------------------------------
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the
Benefits Office has been notified that a qualifying event has occurred. When the qualifying
event is the end of employment or reduction of hours of employment, death of the employee,
commencement of a proceeding in bankruptcy with respect to the employer, or the employee's
becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify
the Benefits Office of the qualifying event.
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or a
dependent child's losing eligibility for coverage as a dependent child),you must notify the
Benefit Office within 60 days after the qualifying event occurs. You must provide this
notice to: Maria Fernandez-Gonzalez, Sr. Benefits Administrator, 1100 Simonton Street, 2-
268, Key West, FL,33040; fax (305) 292-4452.
How is COBRA Coverage Provided?
Once the Benefits Office receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each qualified
beneficiary will have an independent right to elect COBRA continuation coverage. Covered
employees may elect COBRA continuation coverage on behalf of their spouses, and parents may
elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying
event is the death of the employee, the employee's becoming entitled to Medicare benefits (under
Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility
as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When
the qualifying event is the end of employment or reduction of the employee's hours of
employment, and the employee became entitled to Medicare benefits less than 18 months before
the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the
employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered
employee becomes entitled to Medicare 8 months before the date on which his employment
terminates, COBRA continuation coverage for his spouse and children can last up to 36 months
after the date of Medicare entitlement, which is equal to 28 months after the date of the
qualifying event(36 months minus 8 months). Otherwise, when the qualifying event is the end
of employment or reduction of the employee's hours of employment, COBRA continuation
coverage generally lasts for only up to a total of 18 months. There are two ways in which this
18-month period of COBRA continuation coverage can be extended.
11
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security
Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and
your entire family may be entitled to receive up to an additional 11 months of COBRA
continuation coverage, for a total maximum of 29 months. The disability would have to have
started at some time before the 60th day of COBRA continuation coverage and must last at least
until the end of the 18-month period of continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA
continuation coverage, the spouse and dependent children in your family can get up to 18
additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of
the second qualifying event is properly given to the Plan. This extension may be available to the
spouse and any dependent children receiving continuation coverage if the employee or former
employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets
divorced or legally separated, or if the dependent child stops being eligible under the Plan as a
dependent child,but only if the event would have caused the spouse or dependent child to lose
coverage under the Plan had the first qualifying event not occurred.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be
addressed to the contact or contacts identified below. For more information about your rights
under COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other
laws affecting group health plans, contact the nearest Regional or District Office of the U.S.
Department of Labor's Employee Benefits Security Administration(EBSA) in your area or visit
the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and
District EBSA Offices are available through EBSA's website.)
Keep Your Plan Informed of Address Changes
In order to protect your family's rights, you should keep the County's Employee Benefits Office
informed of any changes in the addresses of family members. You should also keep a copy, for
your records, of any notices you send to the County's Employee Benefits Office.
Plan Contact Information
You can obtain information about the Group Health Plan and COBRA from:
Employee Benefits
Senior Benefits Administrator
1 Ioo Simonton Street, Suite 2-268
Key West, FL 33040
(305) 292-4448
12
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN'S HEALTH
INSURANCE PROGRAM (CHIP)
If you or your children are eligible for Medicaid or CHIP and you are eligible for health
coverage from the County, your State may have a premium assistance program that can help pay
for coverage. These States use funds from their Medicaid or CHIP programs to help people who
are eligible for these programs,but also have access to health insurance through their employer.
If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these
premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed
below, you can contact your State Medicaid or CHIP office to find out if premium assistance is
available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or
any of your dependents might be eligible for either of these programs, you can contact your State
Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out
how to apply. If you qualify, you can ask the State if it has a program that might help you pay
the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under
Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit
you to enroll in your employer plan if you are not already enrolled. This is called a"special
enrollment"opportunity, and you must request coverage within 60 days of being determined
eligible for premium assistance. If you have questions about enrolling in your employer plan,
you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling
toll-free 1-866-444-EBSA (3272).
If you live in one of the following States,you may be eligible for assistance paying your
employer health plan premiums. The following list of States is current as of July 31, 2012.
You should contact your State for further information on eligibility—
ALABAMA—Medicaid COLORADO—Medicaid
Medicaid Website:http://www.colorado.gov/
Website: http://www.medicaid.alabama.gov Medicaid Phone(In state): 1-800-866-3513
Phone: 1-855-692-5447 Medicaid Phone(Out of state): 1-800-221-3943
ALASKA—Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone(Outside of Anchorage): 1-888-318-8890
Phone(Anchorage): 907-269-6529
ARIZONA—CHIP FLORIDA—Medicaid
Website: http://www.azahcccs.gov/applicants Website: https://www.flmedicaidtplrecovery.com/
Phone(Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268
Phone(Maricopa County): 602-417-5437 GEORGIA—Medicaid
Website:http://dch.georgia.gov/
Click on Programs,then Medicaid,then Health Insurance
Premium Payment(HIPP)
Phone: 1-800-869-1150
13
IDAHO—Medicaid and CHIP MONTANA—Medicaid
Medicaid Website: www.accesstohealthinsurance.idaho.gov Website:http://medicaidprovider.hhs.mt.gov/clientpages/
Medicaid Phone: 1-800-926-2588 clientindex.shtml
CHIP Website:wwv.►nedicaid.idaho.gov Phone: 1-800-694-3084
CHIP Phone: 1-800-926-2588
INDIANA—Medicaid NEBRASKA—Medicaid
Website:http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949 Phone: 1-800-383-4278
IOWA—Medicaid NEVADA—Medicaid
Website:www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900
KANSAS—Medicaid
Website:http://www.kdheks.gov/hef/
Phone: 1-800-792-48 84
KENTUCKY—Medicaid NEW HAMPSHIRE—Medicaid
Website:http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA—Medicaid NEW JERSEY—Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:http://www.state.nj.us/humanservices/
Phone: 1-888-695-2447 dmahs/clients/medicaid/
Medicaid Phone: 1-800-356-1561
MAINE—Medicaid CHIP Website:http://www.njfamilycare.org/index.html
Website:http://www.maine.gov/dhhs/ofi/public- CHIP Phone: 1-800-701-0710
assistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS—Medicaid and CHIP NEW YORK—Medicaid
Website:http://www.mass.gov/MassHealth Website:http://www.nyhealth.gov/health—care/medicaid/
Phone: l-800-462-1120 Phone: l-800-541-2831 .._
MINNESOTA—Medicaid NORTH CAROLINA—Medicaid
Website:http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma
Click on Health Care,then Medical Assistance Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI—Medicaid NORTH DAKOTA—Medicaid
Website: Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.htm http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 573-751-2005 Phone: 1-800-755-2604
14
OKLAHOMA—Medicaid and CHIP UTAH—Medicaid and CHIP
Website:http://www.insureoklahoma.org Website: http://health.utah.gov/upp
Phone: 1-888-365-3742 Phone: 1-866-435-7414
OREGON—Medicaid and CHIP VERMONT—Medicaid
Website:http://www.oregonhealthykids.gov Website:http://www.greenmountaincare.org/
http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427
Phone: 1-877-314-5678
PENNSYLVANIA—Medicaid VIRGINIA—Medicaid and CHIP
Website:http://www.dpw.state.pa.us/hipp Medicaid Website: http://www.dmas.virginia.gov/rcp-
Phone: 1-800-692-7462 HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website:http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND—Medicaid WASHINGTON—Medicaid
Website: www.ohhs.ri.gov Website:http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone:401-462-5300 Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA—Medicaid WEST VIRGINIA—Medicaid
Website:http://www.scdhhs.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820 Phone: 1-877-598-5820,HMS Third Party Liability
SOUTH DAKOTA-Medicaid WISCONSIN—Medicaid
Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p-10095.htm
Phone: 1-888-828-0059 Phone: 1-800-362-3002
TEXAS—Medicaid WYOMING—Medicaid
Website:https://www.gethipptexas.cotn/ Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 1-800-440-0493 Phone:307-777-7531
To see if any more States have added a premium assistance program since July 31, 2012, or for
more information on special enrollment rights, you can contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare& Medicaid Services
www.dol.gov/ebsa ww.w.cros.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
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CARRIERS AND CONTACT INFORMATION FOR NON-MEDICAL BENEFITS
Prescription Drug Benefit
(administered by EnvisionRx)
Toll-Free Customer Service: (800) 361-4542
Website: www.envisionrx.com
Vision Benefits
(Insured by Vision Service Plan Insurance Company)
Toll-Free Customer Service: (800) 877-7195
Website: www.vsp.com
Dental Benefits
(Insured by United Concordia)
Toll-Free Customer Service: (800) 332-0366
Website: www.unitedconcordia.com
Life,Accidental Death and Dismemberment, and Disability Benefits
(Insured by Hartford Life and Accident Insurance Company)
Toll-Free Disability Claims: (800) 303-9744
Toll-Free Life and AD&D Claims: (800) 563-1124
Website: www.thehaitford.com/employeebenefits
Employee Assistance Program
(Administered by Horizon Health)
Toll-Free Customer Service: (800) 272-7252 (24 hours per day, 7 days per week)
Website: www.HorizonCareLink.com
Login: MCBOCC
Password: MCBOCC
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