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HomeMy Public PortalAboutAV-Med, Inc-VKB Contract Nof AV-MED HEALTTH PLAN A DIVISION OF SANTAFE HEALTHCARE GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT Chief Executive Officer GROUP #04515-001 VILLAGE OF KEY BISCAYNE 85 W McINTYRE STREET KEY BISCAYNE FL 33149 EFFECTIVE 5/1/93 7/88(191) AV G100-88 REV (11/91) ERRATA SHEET This errata applies to the AV MED Group Medical and Hospital Service Contract (AV G100 88) (Printed in the U S November 1991 r) and to the Certificate of Coverage for this Contract The Sections listed below should be corrected as follows Section 3 28 Osceola County is located in the Orlando Service Area (not in the Gainesville Service Area) Section 1017 In the first paragraph of this section delete the words their Plan Physician s opinion about The last paragraph in this section should read as follows The Health Plan may limit second medical opinions in connection with a particular diagnosis or treatment to three per Contract Year if the Health Plan deems additional opinions to be an unreasonable over utilization by the Member If Health Plan determines that more than three second opinions is unreasonable and the Member disagrees the Member may file a grievance with Health Plan Section 10 21 The term at the end of the sentence should be episode (not contract year) The term episode is correctly pnnted m corresponding Contract Sections 11 12 and 12 41 Section 1015 The following words physician and and appear as typographical errors (misspelled words) in this section Section 1018 The following words Services and entitled appear as typographical errors (misspelled words) in this section r MP 1348 (4/92) r TABLE OF CONTENTS SERVICE AREAS i I GENERAL 1 II INTERPRETATION 1 III DEFINITIONS 15 IV ELIGIBILITY 5 6 V ENROLLMENT 6 VI EFFECTIVE DATE OF MEMBERSHIP 6-7 VII MONTHLY PAYMENTS AND COPAYMENTS 7 VIII CONVERSION 7 8 IX TERMINATION 9-10 X. SCHEDULE OF BASIC BENEFITS 11 13 XI LIMITATIONS OF BASIC BENEFITS 14 15 XIL EXCLUSIONS FROM BASIC BENEFITS 15 17 XIII COORDINATION OF BENEFITS 17 18 XIV REIMBURSEMENT 18 XV DISCLAIMER OF LIABILITY 18 XVI REFUSAL TO ACCEPT TREATMENT 18-19 XVIL GRIEVANCE PROCEDURE 19-20 XVIII MISCELLANEOUS 20-22 AV -G100-88 7/88 (1-91) SERVICE AREAS MIAMI SERVICE AREA POST OFFICE BOX 569004 9400 SOUTH DADELAND BOULEVARD MIAMI FLORIDA 33156-9004 (305) 665-5437 1-800-432-6676 FT LAUDERDALE SERVICE AREA 6363 N W 6th WAY SUITE 350 FT LAUDERDALE, FLORIDA 33309 BROWARD (305) 462 2520 PALM BEACH (407) 655-8867 1 800-368 9189 TAMPA BAY SERVICE AREA 2701 ROCKY POINT ROAD SUITE 1050 TAMPA, FLORIDA 33607 PINELLAS (813) 894-6936 HILLSBOROUGH (813) 281 5650 PASCO 1 800-257 2273 GAINESVILLE SERVICE AREA POST OFFICE BOX AB 2815 N W 13th STREET SUITE 200 GAINESVILLE FLORIDA 32602 (904) 372-8666 1-800-237-1255 ORLANDO SERVICE AREA 851 TRAFALGAR COURT SUITE 225 MAITLAND FLORIDA 32751 (407) 660-0333 1 800-227 4848 JACKSONVILLE SERVICE AREA 9424 BAYMEADOWS ROAD SUITE 200 JACKSONVILLE, FLORIDA 32256 (904) 733 8159 1-800-227-4184 IN FLORIDA 1 800-432 6676 ELSEWHERE IN U S A 1 800-228-0660 AV G100.88 i 7188 (1 91) AV-MED, INC. D/B/A AV-MED HEALTH PLAN GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein and of mutual promises and benefits hereinafter described AV MED INC a Florida corporation D/B/A AV MED Health Plan (hereinafter referred to as Health Plan ) and VILLAGE OF KEY BISCAYNE (hereinafter referred to as Subscribing Group ) agree as follows I GENERAL The Subscribing Group engages Health Plan ( the Parties ) to arrange medical and hospital services for the Members of the Subscribing Group who have subscribed for said service in accordance with the covenants and conditions hereinafter provided Health Plan shall rely upon the statements of the Subscriber in his application This contract is not intended to and does not cover or provide any medical services or benefits which are not Medically Necessary for the diagnosis and treatment of the member However only those Medically Necessary services and benefits expressly agreed to herein by the Parties will be covered subject to the terms and conditions set forth in this contract The medical and hospital services covered by this contract shall be provided without regard to the race color religion physical handicap or national origin of the member in the diagnosis and treatment of patients in the use of equipment and other facilities or in the assignment of personnel to provide services pursuant to the provisions of Title VI of the Civil Rights Act of 1964 as amended and Article I Section 2 of the Constitution of the State of Florida II INTERPRETATION In order to provide the advantages of medical and hospital facilities and of the Participating Providers Health Plan operates on a direct service rather than indemnity basis The interpretation of this Contract shall be guided by the direct service nature of the Health Plan program and the definitions and other provisions contained herein III DEFINITIONS As used in this contract the following terms shall have the meaning indicated 3 01 AV MED Inc is a pnvate not for profit Florida corporation state licensed as a health maintenance organization under Chapter 641 Florida Statutes AV MED Inc offers a plan of prepaid services known as the AV-MED Health Plan " AV MED s service areas as defined in Part III Section 3 28 of this Contract are federally qualified (pursuant to Title XII of the Public Health Service Act Section 1310 Subsection (b) in Dade Broward AV -G100-88 1 7/88 (1-91) and Palm Beach Counties (South Florida Service Area) and in Hillsborough Pasco and Pinellas Counties {Tampa Bay Service Area) 3 02 Contract" means this Group Medical and Hospital Service Contract AV -G100-88 (1 91) which may at times be referred to as Group Contract and all applications rate letters face sheets riders amendments exhibits supplemental agreements and schedules which are ormay be incorporated in this Contract from time to time 3 03 Contract Year' means the period of twelve (12) consecutive months commencing on the effective date of this Contract 304 Conversion Contract' means an individual memberorsubscriber contract which shall be available to continue coverage (as provided for therein) of the Subscriber or the Dependent of the Subscriber upon termination of the Subscribing Group Contract as provided in Part VIII of this contract and shall at times be referred to as the Individual or Conversion Contract (AV -C100-88) 305 Copayment means the charge in addition to the prepaid premium charges which the covered Subscriber is required to pay at the time certain health services are provided under this Contract The covered Subscriber/Member is responsible for the payment of any copayment charge(s) directly to the provider of the health services at the time of service The total Copayment paid by any covered Subscriber/Member in any Contract Year shall not exceed the copayment maximum set forth in Exhibit I excluding pharmacy inpatient and outpatient mental health alcohol/drug rehabilitation and elective family planning 306 Custodial Care means services and supplies that are furnished mainly to train or assist in the activities of daily living such as bathing feeding dressing walking and taking oral medicines Custodial Care also means services and supplies that can be safely and adequately provided by persons other than licensed health care professionals such as dressing changes and catheter care or that ambulatory patients customarily provide for themselves such as ostomy care measuring and recording brine and blood sugar levels and administering insulin 3 07 Dental Care means dental x rays examinations and treatment of the teeth or structures directly supporting the teeth that are customanly provided by dentists including orthodontics reconstructive jaw surgery casts splints and services for dental malocclusion 3 08 "Dependent" means any member of a Subscribers family who meets all applicable requirements of Part IV and is enrolled hereunder and for whom the prepayment required by Part VII has actually been received by Health Plan 3 09 Emergency" in Area means the sudden onset of an acute life or limb threatening illness or injury such as by way of example but not limited to heart attack stroke massive Internal or external bleeding fractured limbs or severe trauma This does not include elective or routine care care of minor illness or care that can reasonably be sought and obtained from the Members Primary Care Physician Emergency" Out -of Area means unexpected urgently needed medical care which is required in order to prevent a serious deterioration in health and which cannot be -delayed until return to the Service Area such as by way of example but not limited to lacerations sprains acute infections acute allergic reactions or any of the examples listed for In Area Emergencies This does not include care for conditions in which a Member reasonably could have foreseen the need of such care before leaving the Service Area or care that can safely be delayed until prompt return to the Service Area 310 Exclusion means any provision of#his Contract whereby coverage for a specific hazard or condition is entirely eliminated 311 Full Time Student means one who is attending school and carrying sufficient credits to qualify as a Full Time Student in accordance with the requirements of the school (See Section 4 02 02(f)) 312 "Group Health Insurance (for purposes of PartXlll) meansthat form of insurance covenng groups of persons under a master group health insurance policy issued to any one of the groups listed in Subsections 627 552 (employee groups) 627 553 (debtor groups) 627 554 (labor union and association groups) and 627 5565 (additional groups) Florida Statutes AV G100-88 2 7/88 (1 91) a) The terms amount of insurance and insurance include the benefits provided under a plan of self insurance b) The term insurer includes any person or governmental unit providing a plan of self insurance c) The terms policy insurance policy health insurance policy and group health insurance policy include plans of self insurance providing health insurance benefits 3 13 "Health Plan means AV MED Inc a not for profit Florida Corporation d/b/a Av Med Health Plan which has been certified as a health maintenance organization by the Department of Insurance of the State of Florida to provide or arrange for the provision of the plan of prepaid health benefits and services covered by this Contract 314 Health Professionals means physicians osteopaths nurses chiropractors podiatrists optometrists clinical psychologists nutritionists occupational therapists physical therapists and other profession als engaged in the delivery of health services who are licensed practice under an institutional license individual practice association or other authority consistent with state law and who are Participating Providers of Health Plan 315 Home Health Care Services means services that are provided for a Member who is home bound due to a disabling medical condition and is unable to receive medical care on an ambulatory outpatient basis but does not require 24 -hour nursing care or extended daily attendance by a professional nurse or confinement in a Hospital or Other Health Care Facility Such services include the intermittent services of professional visiting nurses or other Health Professionals for services covered under this Contract medications and supplies that can be administered only by a licensed health professional and participating physician visits 316 `Hospital means any general acute care Hospital with which Health Plan has contracted or established arrangements for inpatient hospital services and/or emergency services and shall at times be referred to as Plan Hospital rte^ 317 Hospital Services (except as expressly limited or excluded by this Contract) means those services for registered bed patients which are 317 01 Generally and customarily provided by acute care general Hospitals within the Service Area 317 02 Performed prescribed or directed by Plan Providers and 317 03 Medically Necessary for conditions which cannot be adequately treated in Other Health Care Facilities or with Home Health Care Services or on an ambulatory basis 318 "Limitation means any provision other than an Exclusion which restricts coverage under this Contract. 319 Master Application means the Subscribing Group application form entitled Master Application that is specifically identified by the same contract form number as the Contract which it brings into effect when it has been completed and executed by the Subscribing Group and Health Plan 3 20 Medically Necessary' means the use of appropriate services or supplies which are required for the diagnosis and/or treatment of a Member's illness or injury in accordance with standards of acceptable medical practice and are not intended solely for the convenience of the Member or the provider The determination as to Medically Necessary will be made by Health Plan 3 21 Medical Office" means any outpatient facility or Physicians office in the Service Area utilized by a Participating Provider 322 Medical Services(except as limited or excluded by this Contract) means those professional services of Physicians and other Health Professionals including medical surgical diagnostic therapeutic and preventive services which are 3 22 01 Generally and customarily provided in the Service Area, AV G100-88 3 7/88 (1 91) 3 22 02 Performed prescribed or directed by Parfrcipating Providers and 3 22 03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness 3 23 Member' means any Subscriber or Dependent, as described in Part Ill Sections 3 08 311 and 3 30 of this Contract and shall at times be referred to as Plan Member 3 24 "Other Health Care Facility(ies) means any licensed facility other than Transitional Care Units and acute care hospitals providing inpatient services such as skilled nursing care or rehabilitative services for which the Health Plan has contracted or established arrangements for providing these services to Members 3 25 Participating Provider' means any Health Professional or group of Health Professionals or Hospital Medical Office or Other Health Care Facility with whom Health Plan has made arrangements or contracted to render the professional health services setforth herein and shall at times be referredto as Plan Provider 3 26 Physician means any participating physician licensed under Chapter 458 (physician) 459 (osteopath) 460 (chiropractor) or 461 (podiatrist) Florida Statutes and shall at times be referred to as Plan Physician Attending Physician means the Plan Physician primarily responsible for the care of a Member with respect to any particular injury or illness 3 27 Primary Care Physician means a Plan Physician engaged in family practice pediatrics internal medicine obstetrics (during pregnancy only) osteopathy or any specially physician from time to time designated by Health Plan as "Primary Care Physician in Health Plans current list of Physicians and Hospitals 3 28 Service Area means the Miami Service Area which includes Dade county the Ft. Lauderdale Service Area which Includes Broward and Palm Beach counties the Tampa Bay Service Area which includes Citrus Hillsborough Pinellas Pasco and Polk counties the Gainesville Service Area which includes Alachua Bradford Columbia Dixie Gilchrist Osceola Levy and Suwannee counties the Orlando Service Area which includes Orange Seminole and Volume counties the Jacksonville Service Area which includes Baker Clay Duval Nassau and St Johns Counties and such other counties into which the AV MED Health Plan may extend its services 3 29 Specialty Health Care Professional means a Health Professional other than the Member's chosen Primary Care Physician 3 30 Subscriber' means a person who meets all applicable requirements of Part IV and enrolls hereunder and for whom the premium prepayment required by Part VII has actually been received by Health Plan 3.31 Subscriber(ing) Group means an employer who negotiates and agrees to contract for the health services and benefits provided herein for its eligible employees and shall at times be referredto herein as employer or contract holder 3 32 `Transitional Care Services" means those services provided to a Member who requires medical care on a 24 -hour basis Such services may be provided in Transitional Care Units as defined herein or in the home for members unable to receive medical care on an ambulatory basis when confinement in a Hospital or Other Health Care Facility is not Medically Necessary (See Section 11 12) 3 33 `Transitional Care Unit means any facility which provides Transitional Care to patients other than acute hospital care including all types of facilities known as sub -acute care units ventilatordependent units alternative care units sub -acute care centers and all other like facilities whether maintained in a free standing facility or maintained in a hospital setting These units specifically do not include facilities known as skilled nursing facilities or rehabilitative facilities or any other type of facility providing services similar to that of a skilled nursing facility or a rehabilitative facility 334 Utilization Management Program includes but is not limited to the four -level program of (1) preadmission review of all elective hospital admissions (2) concurrent review of all hospitalized patients including on site visits if in the service area (3) discharge planning for all hospitalized patients whose need for continuing care after the acute care level of hospitalization has been AV -G100-88 4 7/88 (1 91) determined while hospitalized and (4) appropriate management of outpatient diagnostic and procedural services IV ELIGIBILITY 4 01 To be eligible to enroll as a Subscriber a person must be 4 01 01 A full-time employee of the Subscribing Group who resides within the service area and is actively employed and regularly works the required number of hours per week as set forth in the Master Application for this Contract and 401 02 Employed for the period of time required foreligibilityas set forth in theMasterApplication and 4 01 03 Entitled on his own behalf to participate in the medical and hospital care benefits arranged by the Subscnbing Group under this contract 4 02 To be eligible to enroll as a Dependent a person must reside in the Service Area (except for f below also see Section 6 03) and must be 4 02 01 the spouse of the Subscriber a new spouse must be enrolled within thirty (30) days after marriage in order to be covered or 402 02 a child of the Subscriber provided that the following conditions apply a) The child is the natural child or stepchild of the Subscriber or a child of a covered Dependent of the Subscriber or a legally adopted child in the custody of the Subscnber written evidence of adoption must be furnished to health plan upon request b) The child resides with the Subscriber (except for f and h below) c) The child is under the age of 19 (except for f and g below or Section 404 below) d) The child is pnncipally dependent upon the Subscriber for maintenance and support and is not regularly employed by one or more employers on a full-time basis of thirty (30) hours or more per week e) The child is not married f) The child is age 19 or over but under the age of 23 and enrolled as a Full -Time Student at a college university vocational or secondary school Subscnber is responsiblefor notifying Health Plan when full time attendance commences or terminates and coverage shall commence or terminate upon such notification. Ceasing of coverage will be retroactively applied if Health Plan is notnotified Subscriber agrees to provide documentation of Full Time Student status upon request of Health Plan The child is age 19 or over and is wholly dependent on the Subscriber due to mental retardation or physical handicap (See Section 404) h) In the event an eligible dependeM child does not reside with the Subscriber coverage will be extended where the Subscriber is obligated to provide medical care by court order or by written agreement provided the eligible Dependent resides within the Service Area g) i) In the case of a newborn child Health Plan should be notified in writing pnor to the scheduled delivery date of the Subscriber's intention to enroll the newborn child but such notice shall not be later than 30 days after the birth All services applicable for covered Dependent children under this contract shall be provided to an enrolled newborn child of the Subscriber or to the enrolled newborn child of a covered Dependent of the Subscriber from the moment of birth (as provided in Part X, AV G100-88 5 7/88 (1-91) Section 1010) Any newborn not enrolled as set forth herein shalt not be eligible to enroll until the next regular group open enrollment period of the Subscribing Group 4 03 No person is eligible to enroll hereunder who has had his coverage previously terminated under Part IX Section 9 01 04 except with the written approval of Health Plan 404 Attainment of the limiting age by a dependent child shall not operate to exclude from or terminate the coverage of such child nor shall overage prevent the enrollment of a child while such child is and continues to be both 4 04 01 Incapable of self sustaining employment by reason of mental retardation or physical handicap and 4 04 02 Chiefly dependent upon the Subscriber for support and maintenance provided proof of such incapacity and dependency is furnished to Health Plan by Subscriber within thirty (30) days of the child s attainment of the limiting age and subsequently as may be required by Health Plan but not more frequently than annually after the two year period following the child s attainment of the limiting age. 4 05 During the term of this Contract no changes in the Subscribing Group eligibility or requirements of participation shall be permitted to affect eligibility or enrollment under this Contract unless such change is agreed to by Health Plan V ENROLLMENT 5 01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof the Health Plan may allow an open enrollment period of up to thirty (30) days in which any eligible Subscriber on behalf of himself and his Dependents may elect to enroll in the Health Plan 5 02 Eligible Subscribers and Dependents who meet the requirements of Part IV Sections 4 01 and 4 02 must enroll within thirty (30) days after becoming eligible by submitting application forms acceptable to or provided by Health Plan otherwise the eligible subscriber and dependents may not enroll until the next open enrollment period of the Subscribing Group 503 The eligibility requirements set forth in Part IV shall at all times control and no coverage contrary thereto shall be effective Coverage shall not be implied due to clerical or administrative errors if such would be contrary to Part IV (Also see Section 18 11) 5 04 This Contract at the sole option of Health Plan will not be accepted if at time of initial offering to Subscribing Group or following re enrollment the total enrollment does not result in a predetermined minimum enrollment as established by Health Plan The required minimum group enrollment is included in the rate letter submitted to Subscribing Group VI EFFECTIVE DATE OF MEMBERSHIP Subject to the payment of applicable monthly membership charges set forth in Part VII and to the provisions of this Contract coverage under this Contract shall become effective on the following dates 6 01 Eligible Subscribers and Dependents who enroll dunng the open enrollment period will be covered Members as of the effective date of this Contract or subsequent anniversary thereof 6 02 Subscribers and/or their Dependents who become eligible to enroll after the open enrollment period of the Subscribing Group and who enroll as provided in Section 5 02 will become effective from the date of eligibility 6 03 If a Subscriber acquires an eligible Dependent, the Dependent will be covered from the date of eligibility upon Health Plans receipt of the required written notice and premium not later than thirty (30) days after the date the Dependent first became eligible otherwise the Dependent may not be enrolled until the next open enrollment period of the Subscribing Group AV G100-88 6 7/88 (1 91) 6 04 Coverage for the a newborn child of the Subscriber or the newborn child of the Subscriber's covered Dependent is effective at birth if Sections 4 02 02 {i) and 6 03 are complied with VII MONTHLY PAYMENTS AND COPAYMENTS 701 Subscriber Group or its designated agent shall remit to Health Plan on or before the first day of each month for which coverage is sought on behalf of each Subscriber and his Dependents the monthly premium based on the rate fetter and Master Application Only Members for whom the stipulated payment is actually received by Health Plan shall be entitled to the health servic-s covered under this Contract and then only for the period for which such payment is applicable Failure of the Subscriber Group to pay premiums for the group by the first of the month and not later than the end of the grace period (as provided in Section 7 02) shall result in retroactive termination of the group effective at 1200 am (midnight) on the last day of the month for which premium was paid unless the payment of premiums has otherwise been contractually adjusted and specified by the parties in a fully executed addendum to this contract An additional charge will apply to all late premium payments {See Section 1815) 702 Grace Period This contract has a ten (10) day grace period This provision means that if any required premium is not paid on or before the date it is due it must be paid and received by Health Plan not later than the close of business (500p m ) on the last day of the grace period During the grace period the contract will remain in force pending receipt of premium payment However rf payment is not received by the last day of the grace period termination of this Contract for nonpayment of premium wilt be retroactive to 12 00 am (midnight) on the last day of the month for which premium was paid Note Certain provisions in Section 7 01 may apply if the parties have executed an addendum affecting premium payments 703 Member shall pay premiums applicable supplemental charges or copayments as provided in this Contract and if he fails to do so upon ten (10) days written notice from Plan to Member the Member's rights hereunder shall be terminated Consideration for reinstatement with the Plan shall require a new application and any re -enrollment shall be at the sole discretion of the Plan and shall not be retroactive 7 04 If an individual Member is retroactively terminated (a) due to failure of the Subscriber Group to make a required monthly payment by the first of the month or during the grace period or (b) due to its failure to provide the Health Plan with written notice within thirty {30) days of a Subscriber becoming ineligible then the Subscriber Group and not the Health Plan or the Member shall be responsible for medical expenses incurred by Health Plan in providing benefits to the Member under the terms of this Contract after the effective date of termination (due to such nonpayment of premiums or failure to notify the Plan of the ineligibility) C VIII CONVERSION 801 A Subscriber or covered Dependent whose coverage under the Subscnber Group Contract has been terminated for any reason including discontinuance of the Subscriber Group Contract in its entirety or with respect to a covered class and who has been continuously covered under the Subscriber Group Contract and underany group health maintenance contract providing similar benefits which it replaces for at least 3 months immediately prior to termination shall be entitled subject to the exceptions contained herein to have issued to him or her a conversion contract unless there is a replacement of discontinued group coverage by similar group coverage within 31 days 1) The converting Subscriber and each of the eligible Dependents of the Subscriber who are converting must be Members of the Plan in good standing on the date when their coverage terminates under this Group Contract and all such Subscribers and Dependents after complying with Section 801{2) below shall be covered under the Individual Conversion Contract AV -6100-88 7 7/88 (1-91) 2) A completed status change form requesting conversion shall be sent with the first applicable premium and shall be received not later than 31 days after the date of termination of this Group Contract 3) Dependents may not convert without the Subscriber except a) In the event of the death of the Subscriber Dependents are permitted an automatic conversion privilege and must comply with 2 above b) A former spouse whose coverage would otherwise terminate because of annulment or dissolution of marriage may convert only for the penod the court order requires the Subscriber to provide medical coverageto the former spouse providing the spouse resides within the Service Area and complies with 2 above c) A spouse whose coverage would terminate or a spouse and children whose coverage would otherwise terminate atthesame time or a child with respect to himself by reason of ceasing to be a qualified family member may convert and must comply with 2 above 4) Health careservices rendered to a Member aftertermination and priorto conversion shall be the responsibility of the Member When the conversion application has been timely completed (within 31 days after termination of the Group Contract) and the first premium due has been paid the Plan shall reimburse the Subscriber for any payment made by -the Sbbscriber for covered Medical Slervices under the converted Contract 5) A new conversioh contract is established upon application and paymentof premium on the day following the Member's termination from group coverage (due to ineligibility underthe Group Contract) and continues throtightheend of the calendar year The contract year upon renewal shall be the calendar year 802 Individual contracts shall hot Include supplemental benefits notwithstanding the supplemental benefits included under this Subscriber Group Contract and may in other respects differ from this Group Contract 803 The conversion pnvilege will not apply to a Subscriber or covered Dependent if termination of his coverage under the this contract occurred for any of the following reasons 1) Failure to pay any required premium or contribution 2) Replacement of any discontinued group coverage by similar group coverage within 31 days 3) Fraud or material misrepresentation in applying for any benefits under this contract (See Section 9 01 09) 4) Willful and knowing misuse of Health Plan s membership identification card by the Subscriber or 5) Willfully and knowingly furnishing incorrect or incomplete information to the Plan for the purpose of fraudulently obtaining coverage or benefits from the Plan. 6) Termination from coverage under this Contract in accordance with Section 9 01 04 or 9 01 09 8 04 Conversion After Continuation Coverage When continuation coverage as provided under the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) expires the Subscriber or covered Dependent may be eligible for conversion coverage and may apply by completing an application for an individual conversion contract sublectto the conditionsdescribed in Part V111 above The eligible Subscriber or Dependent must send a completed application and the applicable premium payment postmarked not later than 31 days after the termination of COBRA coverage directly to AV MED Health Plan Accounting Department Suite 310 9400 South Dadeland Blvd Miami Florida 33156 The Subscribe or Dependent may obtain an application form and a statement of current premium rates for the individual conversion contract by calling the Service Area office (see list inside the front cover of this contract) AV -G100-88 8 7188 (1 91) IX TERMINATION All rights and benefits under this contract shall cease as of the effective date of termination unless otherwise provided herein This Contract shall continue in effect for one year from the effective date hereof and may be renewed from year to year thereafter subject to the following 9 01 Reasons for and Effective Dates of Termination 9 01 01 Upon failure to make payment of the monthly charges provided in Part VII within ten (10) days following the due date specified herein benefits hereunder shall terminate for all Members and any Dependents for whom such payment has not been received at 12 00 am (midnight) on the last day of the month for which the monthly premium was paid 901 02 In the event any Subscriber fails to make any of the copayments required under this Contract for such Subscriber or his Dependent(s) benefits hereunder shall terminate for the Subscriber and his Dependent(s) ten (10) days after written notice from the Plan 9 01 03 Health Plan may terminate this Group Contract on the anniversary date by giving written notice to the Subscribing Group thirty (30) days prior to the Contract anniversary date In such event benefits hereunder shall terminate for all Members at 12 00 am (midnight) on the Contract expiration date 9 01 04 If Participating Providers shall be unable to establish and maintain a satisfactory physician - patient or hospital -patient relationship with any Member after reasonable efforts to do so then the rights of such Member and other members of his family under this Contract may be terminated provided the Plan gives not less than thirty (30) -days written notice to the Member Premium prepayments received by the Plan on account of such terminated Member(s) for penods afterthe effective date of termination shall be refunded on a pro rata basis and Health Plan shall have no further liability or responsibility for such Member(s) under this Contract 9 01 05 All rightsto benefits under this Contract shall cease at 12 00 am (midnight) on the effective date of termination (See Section 904) 9 01 06 Membership shall automatically terminate on the earliest of the following dates a) for both Subscriber and Dependents at 12.00 am (midnight) on the date on which this Contract terminates or is terminated b) for both Subscriber and Dependents at 1200 am (midnight) on the date of expiration of the period for which the last membership premium was paid on account of the Subscriber's membership c) for a Dependent at 1200 am (midnight) on the date of expiration of the period for which the last membership premium was paid on account of such Dependents membership or d) fora Dependent at 12.00 am (midnight) on the last day of the month in which the Dependent ceases to be a Dependent as defined in Parts III and IV provided premium was received by the Plan for that month 501 07 When a Dependent becomes ineligible for Dependent coverage due to age the Subscriber is required to notify the Health Plan in writing Premium refunds to Subscribers who fail to providetimely notice and who continue to make payment for ineligible Dependents will be limited to the total excess premiums paid up to a maximum of ninety (90) days from the date such Dependent became -ineligible due to age 90108 Refund of premiums paid to Health Plan by the Subscnber Group for any Member afterthe date on which that Member's eligibility ceased or the Member was terminated shall be limited to the total excess premiums paid up to a maximum of ninety (90) days from the date of such ineligibility or termination AV G100-88 9 7/88 (1-91) 9 01 09 Benefits for any Subscriber or Member who makes fraudulent statements or files fraudulent claims for himself or any eligible Dependent(s) shall at the discretion of the Plan be terminated immediately upon discovery of such fraud by the Plan The Plan shall notify such Subscriber/Member and the Subscnber Group by certified mail Any Subscriber or Dependent who is terminated from group coverage due to fraud shall not be eligible for a Conversion Contract 9 02 Notification of Termination In the event this Contract is terminated the Subscribing Group agrees that it shall notify its employee Subscribers covered under this Contract of the date of such termination Written notice of termination cancellation or nonrenewal shall be given by the Subscribing Group at least 30 days prior to the effective date of termination 902 01 when this contract expires is canceled or not renewed by the Subscribing Group or 90202 when Health Plan notifies the Subscnbing Group of the Plan s intentto terminate cancel or not renew 903 Continuation Coverage Under certain provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) the Subscriber and his Dependent may become eligible for continuation of coverage if one of the following qualifying events occurs 9 03 01 Death of the covered employee (Subscriber) 9 03 02 Termination of employment or reduction of work hours of a covered employee (except for employees gross misconduct) 903 03 Divorce or legal separation of covered employee from spouse 9 03 04 Covered employee becomes entitled to benefits under Medicare 90305 Dependent child of covered employee ceases to be a Dependent under Health Plan provisions The Subscribing Group shall immediately notify the Health Plan if the event in Sections 9 03 01 or 9 03 02 occurs The covered Subscriber is obligated to immediately notify his employer and the Health Plan if the event in Section 90303 90304 or 90305 occurs Continuation coverage will be administered in compliance with Federal laws and regulations currently in effect 9 04 Conversion After Continuation Coverage When continuation coverage as provided under the provisions of the Consolidated Omnibus Reconciliation Act of 1986 (COBRA) expires the Subscriber or covered Dependent may be eligible for conversion coverage and may apply by completing an application for an individual conversion contract, subject to the conditions described in Part VIII above The eligible Subscriber or Dependent must send a completed application and the applicable premium payment postmarked not later than 31 days after the termination of COBRA coverage directly to AV-MED Health Plan Accounting Department Suite 310 9400 South Dadeland Blvd Miami Florida 33156 The Subscriber or Dependent may obtain an applcation form and a statement of current premium rates for the individual conversion contract by calling the Service Area office (see list inside the front cover of this contract) 9 05 Extension of Benefits In the event this Contract is terminated by the Plan for any reason except nonpayment of premium such termination shall be without prejudice to any continuous losses to a Subscriber or Member which/commenced while the Contract was in force but any extension of benefits beyond the date of termination shall be predicated upon the continuous total disability of the Subscriber or Member and shall be limrtedto the duration of the Contract benefit period if greater than three months or fora time period of not less than three months orto the payment of maximum benefits payable under the Contract 0 0 AV G100-88 10 7/88 (1 91) X SCHEDULE OF BASIC BENEFITS The Health Plan assures that the comprehensive prepaid health care services provided its subscribers will be rendered under reasonable standards of quality of care The professional judgement of a physician licensed under Chapters 458 (physician) 459 (osteopath) 460 (chiropractor) or 461 (podiatrist) Florida Statutes concerning the proper course of treatment of a Subscriber shall not be subject to modification by the Health Plan or its Board of Directors Officers orAdministrators However this subsection is not intended to and shall not restrict any Utilization Management Program established by Health Plan All covered services and benefits shall be provided in conformity with Part 111 (Definitions) Part X (Schedule of Basic Benefits) and Exhibit l which by reference is incorporated herein It is the Member s responsibility when seeking benefits under this Contract to identify himself as a Health Plan Member and to assure that the services received by the Member are being rendered by Participating Providers MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR COPAYMENTS WHICH MUST BE PAID TO HEALTH CARE PROVIDERS FOR CERTAIN SERVICES AT THE TIME SERVICES ARE RENDERED AS SET FORTH IN EXHIBIT I rr1 1001 The names and addresses of Plan Providers and Hospitals are set forth in a separate booklet which by reference is made a part hereof The list of Plan Providers which may change from time to time will be provided to all Subscribing Groups Notwithstanding the printed booklet the names and addresses of Plan Providers on file with Health Plan at any given time shall constitutethe official and controlling list of Participating Providers 1002 Within the Service Area Members are entitled to receive the covered services and benefits only as herein specified appropriately prescribed or directed by Participating Providers Within the Service Area the covered services and benefits listed in the Schedule of Basic Benefits are available only from Plan Providers and except for emergency services as provided in Section 10 04 Health Plan shall have no liability orobligation whatsoever on account of services or benefits sought or received by any Member from any nonparticipating physician health professional hospital or other health care facility or other person institution or organization unless prior arrangements have been made for the Member and confirmed by wntten referral or authorization from Health Plan 10 03 Each Member shall select one Primary Care Physician upon enrollment and must notify Health Plan prior to changing Pnmary Care Physicians The Member's change of Primary Care Physicians will become effective on the first day of the month after Member notifies Health Plan and cannot be changed more than once per month Members are entitled to receive the services of Specialty Health Care Professionals only when referred to them by their Pnmary Care Physician except for Emergencies (see Section 3 09) Health Professionals may from time to time cease their affiliation with Health Plan In such cases the Member will be required to select a new PrimaryCare Physician and/or will be referred to a new Specialty Health Care Professional 1004 Any Member requiring medical hospital or ambulance services for Emergencies (as defined in Section 3 09) either while temporarily outside or within the Service Area but before they can reach a Plan Provider may receive the Emergency benefits as specified in Section 1011 1005 Hospital Care Inpatient. All Hospital inpatient services received at Plan Hospitals for non mental illness or injury are provided when prescribed by Plan Physicians andpre-authonzed by Plan Inpatient Services include semi private roam and board newborn nursery care general nursing care meals and special diets when medically appropnate use of operating room and related facilities intensive care unit and services x-ray laboratory and other diagnostic tests drugs and medications biologicals anesthesia and oxygen supplies special duty nursing when medically appropriate and with prior authorization by the Health Plan physical therapy radiation therapy respiratory therapy and administration of blood or blood products See Section 1011 with regard to inpatient emergency services Plan pre -authorization is required for inpatient hospital services for mental illness and/or substance abuse and these services are subject to the conditions set forth in the optional coverage selected (Also see Sections 10 07 03 11 06 11 07 and 11 08 ) 1006 Physician Care Inpatient. Ail Medical Services rendered by Plan Physicians and other Health Professionals when requested or directed by the Attending Physician including surgical procedures AV G100-88 11 7/88 (1 91) anesthesia consultation and treatment by Physician specialist laboratory and x-ray services and physical therapy (see Section 10 08) are provided wh i le the Member is admitted to a Plan Hospital as a registered bed patient 10 07 Physician Care Outpatient 10 07 01 Diagnosis and Treatment All services of Plan Physicians and Other Health Professionals as requested or directed by the Primary Care Physician including surgical procedures routine hearing examinations and vision examinations for glasses for children underage 18 consultation and treatment by Specialist Health Care Professionals and non reusable materials and surgical supplies are provided at Medical Offices These services are subject to limitations as outlined in Part Xi (Limitation of Basic Benefits) 10 07 02 Preventive and'Health Maintenance Services The services of the Member's Primary Care Physician for illness prevention and health maintenance including well baby care immunizations sterilization (see Exhibit I Schedule of Copayments) periodic health assessment and physical examinations are provided 10 07 03 Mental Health Services Services of Plan Physicians and other Health Professionals for diagnosis medical treatment and referral services for mental health are provided only for diagnostic evaluation or crisis intervention (See Section 11 08 )These are subject to the limitations as outlined in Part Xl (Limitations of Basic Benefits) 10 08 Physical Speech Audio and Occupational Therapy Covered prescribed and pre -authorized physical speech audio and occupational therapy benefits are limited to acute conditions which in the Judgement ofthe Attending Physician are subject to significant improvement through short term therapy and not to exceed sixty (60) consecutive calendar days from the first therapy visit per condition (See Section 11 08) Speech therapy for delayed or abnormal speech pathology is not covered 1009 Obstetrical Care Covered obstetrical care benefits as specified herein are provided and include hospital care anesthesia x rays and laboratory services for conditions relating to pregnancy Newborn child care is covered as provided in Section 402 02 (r) and Section 1010 1010 Newborn Care All services applicable for children under this Contract shall be provided to an enrolled newborn child of the Subscriber or the enrolled newborn child of a covered Dependent of the Subscriber from the moment of birth including the necessary care or treatment of medically diagnosed congenital defects birth abnormalities or prematurity and transportation costs to the nearest facility appropriately staffed and equipped to treat the newborns condition when such transportation is Medically Necessary 1011 Emergency Services All necessary Physician and Hospital Services will be provided by the Health Plan for Emergency care (See Part Ill Section 309) Hospital inpatient services following an emergency admission are covered if Health Plan is notified within 48 hours or as soon as the Member is lucid and able to notify Health Plan of an emergency admission Health Plan will pay the usual reasonable customary charges to a non -Plan physician or facility only for those services rendered before a Members condition permits himto be reasonably able to travel to a Plan facility In addition any member requests for reimbursement (of payment made by the member for sevices rendered) must be filed within ninety (90) days of the emergency or as soon as reasonably possible but not later than one (1) year unless the claimant was legally incapacitated 1012 Ambulance Service For an acute life or limb threatening injury or illness or when authorized by Health Plan ambulance service to the nearest hospital appropriately staffed and equipped to treat the condition will be provided without charge to the Member 1013 Other Health Care Facility(ies) All routine services of Other Health Care Facilities (see Section 3 24) including Physician visits physiotherapy x rays and laboratory work are provided for a maximum of twenty (20) days per contract year when a Member is admitted to such a facility following discharge from a hospital for a condition that cannot be adequately treated with Home Health Care Services or on an ambulatory basis 0 AV G100-88 12 7/88 (1-91) 10 14 X Ray and Laboratory All prescribed x ray and laboratory tests and services including diagnostic x rays fluoroscopy electrocardiograms blood and urine and other laboratory tests and diagnostic clinical isotope services are provided when Medically Necessary and ordered by a Plan Physician as obligations of Health Plan and that judgement is controlling 1015 Home Health Care Services With prior authorization by Health Plan Home Health Care Services (as defined in Section 315) are provided fora Member who is home -bound when ordered by and under the direction of the Member's Attending Pysician Medical equipment amd homemaker or other Custodial Care services are not covered 1016 Hospice Services With prior authorization by Health Plan services are available from a Health Plan affiliated hospice organization for a Member whose Plan Physician has determined the Member's illness will result in a remaining life span of six (6) months or less 1017 Second Medical Opinions A second medical opinion may be obtained if the Plan or Member requests it for an elective surgery or when a Member 1) questions their Plan Physician s opinion about the appropriateness or necessity of a covered surgical procedure that was recommended by a Plan Physician or 2) is subject to a life -threatening injury or illness With prior notice to Health Plan the Member may obtain the secondemedical opinion from any Plan or non Plan Physician chosen by the Member who is within the Health Plan s Service Area If a Plan Physician is chosen there is no cost to the Member other than any applicable copayment If the Member chooses a non Plan Physician the Member will be responsible for a portion of the non Plan Physician s charge as shown in the Schedule of Copayments {Exhibit I) Any tests that may be required to render the second medical opinion must be arranged by the Health Plan and performed by Plan Providers Once a second concurring medical opinion has been rendered and the Member's Primary Care Physician reviews and concurs he will determine the treatment obligations of Health Plan and that judgement is controlling in the event the first two medical opinions do not agree on a recommended procedure a third opinion confirming one of the prior medical opinions will be controlling as to the procedure Any treatment the member obtains that is not authorized by the Plan shall be at the Member's expense and the Plan shall not be liable for any complications or other expenses which may result from the unauthorized treatment The Health Plan may limit second medical opinions in connection wrth a particular diagnosis treatment om a Health Plan affiliated hospice organization for a Member whose Plan Physician has determined the Member's illness will result in a remaining life span of six (6) months or less 1018 Payment to Nonparticipating Providers When in the professional judgement of the Plan s Medical Director a Member needs covered medical or hospital services which requires skills or facilities not availablefrom Plan Providers and it is in the best interest of the Member to obtain the needed care from a non participating provider upon authorization by the Medical Director payment of the reasonable charges for such covered srevices rendered by a nonparticipating provider will be made by Health Plan Charges for non plan hospital services will be reimbursed in accordance with the covered benefits the Member would be inbtled to receive in a Plan hospital 1019 Prescription Drug Benefits Prescnption drugs are a covered benefit when the Subscribing Group Contract includes a supplemental Prescription Drug Rider 10 20 Copayment Maximum. The total of all Copayments paid by any covered Subscnber/Member in any contract year shall not exceed the Copayment Maximum set forth in Exhibit 1 excluding pharmacy inpatient and outpatient mental health alcohol/drug benefits and elective family planning The Subscriber/Member is responsible for the recovery of any excess Copayment paid (by the Subscriber/Member) to a Plan provider 10 21 Transitional Care Services With prior authorization by Health Plan Transitional Care Services (see Section 3 32) are provided up to a total of 150 days per Contract Year 1022 Major Organ Transplants are covered except those deemed experimental (see Section 12 23) AV G100-88 13 7/88 (1 91) Xi LIMITATIONS OF BASIC BENEFITS The rights of Members and obligations of Plan Providers hereunder are subject to the following limitations 11 01 In the event of any major disaster Participating Providers shall render hospital and medical services provided under this Contract insofar as practical according to their best judgement within the limitations of such facilities and personnel as are then available but Health Plan and Plan Providers shall have no liability or obligation for delay or failure to provide or arrange for such services due to lack of available facilities or personnel if such lack is the result of any major disaster 11 02 In the event of circumstances not reasonably within the control of Health Plan such as complete or partial destruction of facilities act of God war riot civil insurrection disability of a significant part of Hospital or participating medical personnel or similar causes the rendition of medical and hospital services provided under this Contract is delayed or rendered impractical, neither Health Plan Participating Providers nor any Physician shall have any liability or -obligation on account of such delayor failure to provide services however Health Plan shall make a good faith effort to arrange for the timely provision of covered services during such event 11 03 Penodic physical examinations are limited to those which in the judgement of the Members Primary Care Physician are essential to the maintenance of the Members good health. t 11 04 If a Member is covered under more than one Contract with Health Plan he shall be covered under one but not both The refund of any premium payments made under such other contract shall belimited to the smaller of the amount of overpayment or the amount overpaid during the ninety (90) days immediately preceding the date on which the Plan received the notice of overpayment from the Subscriber Group or Member 1105 A Member must select a Primary Care Physician from Health Plan s directory as of the effective date of coverage and not later than thirty (30) days thereafter Benefits will not be provided until a selection has been made The Member may obtain assistance if necessary by contacting the Than 11 06 Mental Health Services Hospital Limitation The covered mental health services of Plan Hospital or Other Health Care Facility when a Member is admitted for mental or psychiatric services shall be limited to twenty one (21) days per contract year is available only under the High Option Contract and requires a Copayment (See Exhibit I) Inpatient services for alcohol and drug abuse shall be provided but only for acute detoxification and the treatment of other medical sequelae of such abuse Alcohol or drug rehabilitation services are not covered 11 07 Mental Health Services Physician Limitation The covered mental health services provided by a Plan Physician while a Member is a registered bed patient of a Plan Hospital or Other Health Care Facility shall the limited to twenty one (21) days per contract year and each Plan Physician visit requires a Copayment (See Exhibit I) 11 08 Outpatient Mental Health Services are limited to diagnostic evaluation and crisis intervention only These services are limited to a total of twenty (20) outpatient visits per contract year Referral for outpatient mental health services must be arranged by the Members Plan Physician and each visit requires a Copayment (See Exhibit I) 11.09 Physical speech audio or occupational therapy is limited to acute conditions which in the judgment of the Attending Physician are subject to a significant improvement through short term therapy fora period not to exceed sixty (60) consecutive calendar days from the first therapy visit per condition and each visit requires a Copayment (See Exhibit I) 11 10 Visits to Plan physicians or nutritionists for obesity control shall be limited to those necessary to establish a program of obesity control and each visit requires a Copayment (See Exhibit I and also Section 12 22) 11 11 Spinal manipulations will be provided only when Medically Necessary and prescribed by a Plan Physician or by self referral to a Plan physician 11 12 The total benefit for Transitional Care Services is limited to 150 calendar days per episode C AV -G100-88 14 7/88 (1 91) 11 13 Major organ transplants are covered as authorized by the Health Care Financing Administration and those transplants deemed nonexperimental by the American Medical Association 11 14 Inpatient hospital care fora medical Emergency in area or out of area will only be covered when authonzed by the Plan afterthe Member or the Hospital notifies the Plan within 48 hours of admission 11 15 Treatment for infertility shall be provided only for as long as there is reasonable expectation for pregnancy to occur Such determination shall be made by the Medical Director of Health Plan Surgery for enhancement of fertility shall be provided however see Section 12 25 Physician and facility services associated with surgery for the enhancement of fertility shall require a Copayment (See Exhibit I) XII EXCLUSIONS FROM BASIC BENEFITS Medical services and benefits for the following classifications and conditions are not covered and are excluded from the Schedule of Basic Benefits provided under this Contract 1201 Psychiatric care for mental and nervous disorders except as provided in Sections 1005 10 07 03 11 06 11 07 and 11 08 1202 Cosmetic surgery cosmetic therapy or reconstructive surgery except for reconstructive surgery that is Medically Necessary to restore a normal bodily function in the treatment of deformities that are apparent at birth or that resulted from surgery or acute accidental injury (See Section 12 38) 1203 Medical care or surgery not authorized by a Plan Participating Provider or not within the benefits covered by the Plan including any complications resulting from such surgery or medical care except for Emergency services (as defined in Part III Section 3 09) when rendered as provided in Part X Section 1011 1204 Dental Care for any condition except a) when such services are for the treatment of trauma related fractures of the jaw or facial bones or for the treatment of malignant tumors b) reconstructive jaw surgery for the treatment of deformities that are present and apparent at birth provided the member was continuously covered by AV MED from date of birth to date of surgery or c) full mouth extraction when required before radiation therapy for malignant disease 1205 TMJ surgery and any related hospitalization anesthesia and ancillary services 1206 Mandibular and maxillary osteotomies except as in Section 12 04 (a) 12 07 Artificial aids (such as crutches) and corrective appliances {such as braces) prosthetic devices of all types hearing aids and corrective lenses and the professional fee for fitting same home monitoring devices and measuring devices ventilator equipment nebulizers inhalers and any other equipment or devices for use outside the Hospital This exclusion also applies to surgically implanted devices and/or appliances except for cardiac pacemakers intraocular lens artificial joints and orthopedic hardware vascular grafts and other surgical material 12 08 Over-the-counter medications all contraceptives hypodermic needles and syringes and injectable drugs except chemotherapy for cancer patients insulin and insulin syringes allergy serums and any medication administered by the Attending Physician 1209 Ambulance services except in accordance with Section 1012 1210 Treatment for chronic alcoholism and chronic drugaddichon except those services offered as a basic health service {see Section 11 06) 1211 Treatment for service -connected disabilities for which the Veterans Administration and military hospital system provide care to which the Member is legally entitled and when such facilities are reasonably available within the Service Area AV G100-88 15 7/88 (1 91) 1 l i 12 12 Custodial Care (as defined in Part Ill Section 3.06) 1213 Experimental procedures or procedures not consistent with accepted medical standards Health Plan will determine whether a procedure is experimental based upon an objective review consistent with accepted medical standards and subject to review by the Plans Member Appeals Committee if requested by the Member 12.14 Personal comfort items not Medically Necessary for proper medical care 1215 Care for conditions that state or local law requires to be treated in a public facility 12 16 Any court -ordered treatment or hospitalization 1217 Physical examinations or tests such as premarital blood tests or tests for continuing employment education licensing or insurance or that are otherwise required by a third party 1218 Eye examinations for Plan Members 18 years of age or older for the purpose of determining the need for sight correction (such as eye glasses or contact lenses) 1219 Eye exercises 12 20 Hearing examinations for Plan Members 18 years of age or olderfor the purpose of determining the need for heanng correction 1221 Cosmetics dietary supplements nutritional formulae health or beauty aids 12 22 Gastric stapling gastric bypass gastric bubbles and other experimental or investigational surgical procedures for the treatment of obesity 1223 Major orgarrtransplants deemed experimental by the Health Care Financing Administration or by the Amencan Medical Association 12 24 Transsexual surgery and penile prostheses for sexual purposes 1225 In vitro fertilization and embryo transplantation and the chemotherapeutic protocol forenhancement of fertility and artificial insemination 12 26 Reversal of sterilization procedures 12 27 Immunizations and medications for the purpose of foreign travel or employment 1228 Acupuncture biofeedback hypnotherapy sleep therapy sex therapy behavioral training and vocational rehabilitation 12 29 Routine foot care including trimming of corns calluses and nails 12 30 The medical and hospital services for a donor or prospective donor who is a Plan member when the recipient of art organ transplant is not a Plan Member 12 31 Educational and other nonmedical treatment for mental retardation or learning disabilities 12 32 Emergency room services for non emergency purposes (See Section 3 09 ) 12 33 Hospital services that are associated with excluded surgery or Dental Care 12 34 Any non plan treatment received by a Member except in the case of an Emergency or when specifically pre -authorized by Health Plan (See Section3 09 ) 1235 Physical speech audio or occupational therapy except when part of a short term rehabilitation program as provided in the Schedule of Basic Benefits Therapy for chronic conditions is excluded 1236 Alcohol or substance abuse rehabilitation vocational rehabilitation cardiac rehabilitation pulmonary rehabilitation long-term rehabilitation or any other rehabilitationprogram 12 37 Radial Keratotomy or any other corneal surgical procedure to correct refractive error 12.38 Surgery forthe reduction or augmentation of the size of the breasts AV -G100-88 16 7/88 (1 91) 12 39 Termination of pregnancy unless deemed Medically Necessary by the Medical Director subject to applicable state and federal laws or as specified in The Elective Termination of Pregnancy supplement to the Subscribing Group Contract AV G100-88 (1-91) 1240 Hospital Exclusion If a Member elects to receive hospital care from a non Plan attending physician or a non -Plan hospital then coverage is excluded for the entire episode of care except when the admission was due to an Emergency or wi h prior written authorization of Health Plan 12 41 Transitional Care Services except for a maximum of 150 days per episode as provided in Part X (Schedule of Basic Benefits) Section 10 21 XIII COORDINATION OF BENEFITS 13 01 The services and benefits provided under this Contract are not intended and do not duplicate any benefit to which Members are entitled under any otherGroup Health Insurance HMO Personal Injury Protection under the Automobile Insurance Laws of this or any other jurisdiction governmental organization agency or any other entity providing health or accident benef its to a Member including but not limited to Medicare Workers Compensation Public Health Service Champus Maritime Health Benefits or similar state programs as permitted by contract policy or law Health Plan coverage will be primary to Medicaid benefits 13 02 If any covered person is eligible for services or benefits under two or more plans as set forth in Section 1301 the coverage under those plans will be coordinated so that up to but not more than 100% of any eligible expense will be paid for or provided by all such plans combined The Member shall execute and deliver such instruments and papers as may be required and do whatever else is necessary to secure such rights to Health P an Failure to do so will result in nonpayment of claims 13 03 The standards governing the coordination of benefits are the following pursuant to the provisions of Section 627 4235 Florida Statutes 1) The benefits of a policy or plan which covers the person as an employee Member or Subscriber other than as a Dependent are determined before those of the policy or plan which covers the person as a Dependent 2) Except as stated in paragraph (3) when two or more policies or plans cover the same child as a Dependent of different parents a) The benefits of the policy or plan of the parent whose birthday excluding year of birth falls earlier in a year are determined before those of the policy or plan of the parent whose birthday excluding year of birth falls later in that year but b) If both parents have the same birthday the benefits of the policy or plan which covered the parent for a longer period of time are determined before those of the policy or plan which Covered the parent for a shorter period of time However if a policy or plan subject to the rule based on the birthday of the parents as stated above coordinates with an out -of state policy or plan which contains provisions under which the benefits of a policy or plan which covers a person as a dependent of a male are determined before those of a policy or plan which covers the person as a dependent of a female and if as a result the policies or plans do not agree on the order of benefits the provisions of the other policy or plan shall determine the order of benefits 3) If two or more policies or plans cover a dependent child of divorced or separated parents benefits for the child are determined in this order a) First the policy or plan of the parent with custody of the child b) Second the policy or plan of the spouse of the parent with custody of the child and c) Third the policy or plan of the parent not having custody of the child However if the specific terms of a court order state that one of the parents is responsible for the health care expenses of the child and if the entity obliged to pay or providethe benefitsof the policy or plan of AV -G100-88 17 7/88 (1 91) that parent has actual knowledge of those terms the benefits of that policy or plan are determined first This does not apply with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before that entity has that actual knowledge 4) The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired or as that employees dependent are determined beforethose of a policy or plan which covers that person as alaid off or retired employee oras that employees dependent If the other policy or plan is not subject to this rule and if as a result, the policies or plans do not agree on the order of benefits this paragraph shall not apply 5) If none of the rules in paragraphs (1) (2) (3) or (4) determine the order of benefits the benefits of the policy or plan which covered an employee member or subscriber for a longer period of time are determined before those of the policy or plan which covered that person for the shorter period of time 6) Coordination of benefits -shall not be permitted against an indemnity -type policy an excess insurance policyas defined in Section 627 635 Florida Statutes apolicy with coverage limited to specified illnesses or accidents or a Medicare supplement policy XIV REIMBURSEMENT In the event that Health Plan provides medical benefits or payments to a Member who suffers injury disease or illness by virtue of a negligent act or omission by a third party Health Plan shall be entitled to reimbursement from the Member or third party on a fee for service basis for the reasonable value of the benefits or payments provided to the member However Health Plan shall not be entitled to reimbursementfor medical expenses in excess of the Members monetary recovery from the third party Member shall execute and deliver any and all instruments and papers as may be required by Health Plan and do whatever else is necessary to secure such recovery rights of Health Plan XV DISCLAIMER OF LIABILITY 15 01 Neither Subscribing Group nor its agents servants or employees nor any Member is the agent or representative of Health Plan and none of them shall be liable for any acts or omissions of Health Plan its agents or employeesor of a Plan Hospital or a Plan Physician or any other person or organization with which Health Plan has made or hereafter shall make arrangements for the performance of services under this Contract 1502 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to Health Plan or Plan Providers except as specifically setforth herein provided all procedures set forth herein are followed 15 03 Neither Health Plan nor its agents servants or employees nor any Member is the agent or representative of the Subscriber Group and none of them shall be liable for any acts or omissions of Subscriber Group its agents or employees or any other person representing or acting on behalf of Subscriber Group 15 04 The Health Plan does not employ any practicing physicians nurses or medical personnel nor any hospital personnel or physicians nor any health care personnel who may be listed from time to time in the Plans Provider Directory These health care providers are independent contractors and are not the agents or employees of Health Plan Therefore Health Plan shall not be liable for any negligentact or omission committed by any practicing physicians nurses or medical personnel nor any hospital or health care facility its personnel other health care professionals or any of their employees or agents who may from time to time provide medical services to a Member of the Plan Furthermore the Health Plan shall not be vicariously liable for any negligent act or omission of any health care professional who treats a Member(s) of the Health Plan XVI REFUSAL TO ACCEPT TREATMENT 1601 Certain Members may for personal reasons refuse to accept procedures or treatment recommended by Plan Physicians Plan Physicians may regard such refusal to accept their recommendations as AV G100 88 18 7188 (1-91) incompatible with the continuance of the physician patient relationship and as obstructing the provision of proper medical care If a Member refuses to accept the medical treatment or procedure recommended by the Plan Physician and if in the Judgement of the Plan Physician no professionally acceptable alternative exists or if an alternative treatment does exist but is not recommended by the Plan Physician the Member shall be so advised If the Member continues to refuse the recommended treatmentor procedure then neitherHealth Plan nor Plan Physician shall have any further liability or responsibility to provide care for the condition under treatment nor for the consequences of non treatment or non -recommended treatment In such case Health Plan may terminate the individual (s) Su bscri ber(s) coverage under this Contract as set forth in Part 1X Section 9 01 04 16 02 If a Plan Physician recommends a surgical procedure that is not recommended by the second opinion consulting physician the Member shall have the right to consult a third physician The procedure recommended by any two physicians shall control as to the procedure (See Part X Section 1017) XVII GRIEVANCE PROCEDURE 17 01 Onevance Procedure Members are entitled to have any complaint regarding the services or benefits under this Contract reviewed by the Health Plan which is obliged to resolve such complaint in an equitable fashion according to Health Plans Complaint/Grievance Procedures then in effect The Primary Care Physician and/or the Medical Director shall participate in any subscriber grievance where the appropriateness of treatment or quality of care is an issue A Member with a complaint shall take the following steps 1701 01 STEP 1 INFORMAL PROCEDURE Contact the PRIMARY CARE PHYSICIAN directly if there is a question or problem related to the health care Member sought or received from the Physician OR Contact the EMPLOYERS PERSONNEL OFFICE if there is ar administrative problem (for example if the Health Plan does not have a correct record of the Member's Dependent coverage) OR Call the Health Plans MEMBER PROVIDER SERVICES Office located in the Member's Service Area if there is a question or problem related to a claim benefit coverage or any other similar issue Member Provider Services will discuss the concern and within ten (10) business days after receiving the members question will contact the Member with a resolution If the problem or question cannot be resolved immediately the Member will be notified The SERVICE AREA ADDRESS and TOLL FREE PHONE NUMBER are as follows AV MED HEALTH PLAN MEMBER PROVIDER SERVICES MIAMI 9400 S Dadeland Blvd (305) 665 5437 Miami FL 33156 1 800-432 6676 FT LAUDERDALE Suite 350 (305) 462-2520 6363 N W 6th Way (407) 655-8867 Ft Lauderdale FL 33309 1 800-368-9189 TAMPA Suite 1050 (813) 894-6936 2701 Rocky Pt Rd (813) 281 5650 Tampa FL 33607 1-800-257 2273 ORLANDO Su to 225 (305) 660-0333 851 Trafalgar Ct 1 800-227 4848 Maitland FL 32751 GAINESVILLE 2815 N W 13th St Suite 200 (904) 372-8666 Gainesville FL 32609 1 800-237-1255 AV -G100 88 19 7/88 (1-91) JACKSONVILLE Suite 200 (904) 733-8159 9424 Baymeadows Road 1 800-227 4184 Jacksonville FL 32256 17 01 02 STEP 2 FORMAL PROCEDURE If the Member is not satisfied with the decision at Step 1 the Member may flea WRITTEN APPEAL within thirty (30) business days after receiving notice of the decision in Step 1 with the MEMBER RELATIONS OFFICE as follows Member Relations AV MED Health Plan P O Box 823 Gainesville Florida 32602 0823 1 800-346 0231 The Written Appeal should describe the problem in detail give the reasons why the Member is appealing and the solution the Member is seeking Any supporting documentation the Member has should be sent with the appeal If the Member wants help inpreparmgtfteappeal the Mem bershould call1 800-346 0231 and ask for the MEMBER RELATIONS OFFICE The MEMBER RELATIONS OFFICE will review the matter and advise the Member of its resolution or status within ten (10) business days or will schedule a review by the Member Appeals Committee The Member will be given an opportunity to make a statement to the Member Appeals Committee Written notice of the Committees decision will be sent to the Member within three (3) business days following the Committees review If the Member wants to appeal the Plan s final decision (made at STEP 2) the Member may contact one of the following state agencies Department of Insurance Bureau of Specialty Insurers HMO Section Larson Building Room 637 Tallahassee FL 32301 Department of Health and Rehabilitative Services HMO Section OR 2727 Mahan Drive Tallahassee FL 32308 XVIII MISCELLANEOUS 18 01 Contracting Parties By executing this Contract Subscribing Group makes and Health Plan agree to make the medical and hospital services specified herein available to persons who are eligible under the provisions of Part IV However the delivery of benefits and services under this Contract shall be subject to the provisions limitations and exclusions set forth herein and any amendments modifications and Contract termination provisions specified herein and by the mutual agreement between Health Plan and Subscribing Group without the consent or concurrence of the Members By electing or accepting medical and hospital or other benefits hereunder all Members legally capable of contracting and the legal representatives of all Members incapable of contracting agree to all terms conditions and provisions hereof No changes or amendments to this Contract shall be valid unless approved by an executive officer of Health Plan and endorsed herein or attached hereto No agent has authority to change this Contract or to waive any of its provisions 18 02 Certificate of Coverage Plan shall provide a copy of the Certificate of Coverage for each Subscriber 1803 MembershipApplication Members or applicants for membership shall complete and submit to Health Plan such applications or other forms or statements as Health Plan may reasonably request If Member or applicant fails to provide accurate information which Health Plan deems matenal then upon ten (10) days written notice Health Plan may deny coverage and/or Membership to such individual AV G100-88 20 7/88 (1 91) 1804 Membership Cards Cards issued by Health Plan to Members pursuant to this Contract are for purposes of identification only Possession of a Health Plan identification card confers no right to health services or other benefits under this Contract To be entitled to such services or benefits the holder of the card must in fact be a Member on whose behalf all applicable charges under this Contract have actually been paid and accepted by Health Plan 18 05 Physical Examination Health Plan at its own expense shall have the right and opportunity to physically examine the Member when and as often as it may reasonably require during the pendency of a claim hereunder 18 06 Statute of Limitations A claim which has not been timely filed with the Health Plan shall be considered waived if on the date notice of it is received by the Health Plan that claim would otherwise have been barred by any Florida Statute of Limitations if asserted in a civil court 1807 Non Waiver The failure of Health Plan to enforce any of the provisions of this Contract orto exercise any options herein provided or to require timely performance by any Member or Subscriber Group of any of the provisions herein shall not be construed to be a waiver of such provisions nor shall it affect the validity of this Contract or any part thereof or the right of Health Plan to thereafter enforce each and every such provision 18 08 Plan Administration Health Plan may from time to time adopt reasonable policies procedures rules and interpretations to promote the orderly and efficient administration of this Contract 18 09 Notice Any notice intended for and directed to a party to this contract unless otherwise expressly provided should be sent by United States mail postage prepaid addressed as follows ta If to Health Plan to If to a Member If to Subscribing Group AV-MED Health Plan P 0 Box 823 Gainesville Florida 32602 0823 (OR if from a Member to Health Plan see the Member's Service Area address above in Section 17 01 01) To the last address provided by the Member and actually received by Health Plan on the enrollment or change of address notification VILLAGE OF KEY BISCAYNE 85 W McIntyre Street Key Biscayne, FL 33149 1810 Gender Whenever used the singular shall mclude the plural and the plural the singular and the use of any gender shall include all genders 1811 Clerical Errors Clerical error(s) if discovered not later than the earlier of ninety (90) days after the error occurred or the next anniversary date of the contract shall not deprive any individual Memberof any benefits or coverage provided under this Group Contract nor shall such error(s) act as authorization of benefits or coverage for the Member that is not otherwise validly in force Failure of the Subscribing Group to report the termination of coverage for any individual Subscriber shall not continue such coverage beyond the date that it is scheduled to terminate according to the terms of this Contract Neither the inadvertent delay nor the advance remittal of coverage information including prepayment of individual Member premiums or other clerical errors in maintaining or reporting data relative to coverage under this Group Contract shall invalidate coverage which would otherwise be validly in force or continue coverage which would otherwise be validly terminated except that this contract shall terminate for nonpayment Of premiums when due as provided herein 1812 Contract Review Subscribing Group may if this Contract is not satisfactory for any reason return this Contract within three (3) days after receipt and receive a full refund of the deposit paid if any unless the services of Health Plan were utilized during the three (3) days If this Contract is not returned within three (3) days after receipt then this Contract shall be deemed to have been accepted AV G100 88 21 7188 (1-91) 1813 Premium Tax If any government entity shall impose a premium tax or surcharge then the sums due from the Subscribing Group under the terms of this Contract shall be increased by the amount of such premium tax or surcharge 18 14 Entirety of Contract. This Agreement and all applicable Schedules Exhibits Riders and any other attachments and endorsements constitute the entire contract between the Subscribing Group and `. Health Plan No modification (or oral representation) of this Group Contract shall be of any force or effect unless it is in writing and signed by both parties 1815 Rate Letter The rate letter' is the Health Plans formal notice to the Subscribing Group of the premium rates applicable to the group the conditions under which the rates are valid the premium payment terms and due dates the additional charge which will apply to all late premium payments the Plan s reservation of the nght to adjust (re -rate) the premium quote to account for changes in the group size or in the data supplied by theSubscribing Group to Health Plan the applicable employer employee contribution to the premium payment and the charge for other optional supplemental benefits selected by the group if any AV -G100-88 22 7/88 (1 91) Monthly Charges Monthly Membership Charges Subscriber Only _ _ _ _ _ $ 168 52 ._ ._ _ Subscriber plus Spouse _ _ _ $ 337 03 Subscriber plus one Dependent (No Spouse) — $ 337 03 Subscriber plus 2 or more Dependents (No Spouse)_ __ _ $ 488 70 Subscriber plus Spouse and one or more Dependents $ 488 70 ()Other_ _ ___ _ _ $ The provisions contained in the Schedule of Copayments (Exhibit I) applicable to this Contract and all Exhibits and Riders executed by the parties and attached hereto are by reference made a part of this Contract AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written The Effective Date of this Contract, AV -G900-88 is Subscnbing Group VILLAGE OF KEY BISCAYNE By - Signature Name Title May 1 AV MED Inc d/b/a AV-MED Health Plan 19 93 Signature Rafael T Rodriguez Name Director of Marketing Date Date AV 0100$8 Title 7188(1191) AV-MED Health Plan (High Option) Schedule of Copayments Exhibit l i Services 1) In AV-MED Participating Medical Offices - Office visits (Pnmary Cam Physician) $5 00 per visit - Visit to Specialist $500 per visit - Allergy injections $6 00 per visit - Allergy skin testing $p50 00 per visit - Hearing tests (through age 17 only) $5 00 per visit - Vision examination (through age 17 only) $500 per visit - Surgery for the enhancement of fertility (surgeons fee) $100 00 copayment - Infertility evaluation and treatment $20 00 per visit - Mental Health_ Outpatient Physician Visit $20 00 per visit Inpatient Physician Visit $20 00 per visit - Nutritionist $5 00 per visit - Obesity Control - Initial Visit $5 00 per visit Obesity Control - Follow up Visit $15 00 per visit - Physical Speech Audio & Occupational (see exclusion section) $5 00 per visit - Spinal Manipulations $5 00 per visa - Surgery for the purposes of sterilization $100 00 copayment - Obstetncat care (pre and post natal) $5 00 copayment per visit (Only those benefits requiring copayments are listed) Subscriber Cooaym%li 2) Medically necessary services provided in AV-MED participating hospitals or Ambulatory Surgery Centers_ Emergency room services $30 00 copayment Admissions for Mental Health or Psychiatric Service $100 00 per day - Admission for surgery for the purposes of Fertility Enhancement $500 00 copayment 3) Services by non -participating hospitals facilities and/or physicians NO COVERAGF except the following - In area emergency $50 00 copayment - Out -of -area emergency $50 00 copayment 4) Maximum Copayment (Per contract year) 5) Second Medical Opinions - By participating physician - By non participating plysiaan AV -G100 -H-88 Subscriber - $1 000 Subscriber plus one (1) depen- dent -$1500 Subscriber plus 2 or more depen- dents - $2500 (not including elec- five Supplemental Benefits such as but not limited to Prescription Drug Inpatient Mental Health d any) $5 00 copayment 40% of charges 7188(1/91) Attachment E AV-MED Health Plan Alcohol & Drug If selected for an additional premium the following coverage is provided for the treatment of alcohol or drug dependency An intensive outpatient treatment program of one or more weeks by participating providers is covered limited to a total of six (6) weeks per contract year and subject to a member copayment of $50 per week AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written Subscnbing Group VILLAGE OF KEY BISCAYNE AV-MED Inc d/b/a AV MED Health Plan By- BY Signature P 27 A �r 1y��/ Signature '/ Rafael T Rodriguez Name Name Director of Marketing Date Date rue AV -G100 -AD -E-88 7/88(1 91} AV MED HEALTH PLAN OPTIONAL EXTENDED PRESCRIPTION DRUG BENEFITS (Prescription Plus Program) If selected for an additional premium the following optional coverage is hereby added (1) Copayment $ 700 copayment Generic Prescription Drugs $12.00 copayment Brand Prescription Drugs (2) Oral Contraceptives (check one) Yes No X The Prescription Plus Program covers outpatient medications which require a prescription and are prescribed by the member's AV MED physician or an AV MED specialist to whom the member has been referred. The Prescription Plus Program covers up to a 30 -day supply of a medication for the above listed copayment The amount of medication per copayment is limited to the amount presented by your physician which will be sufficient to treat an acute phase of an illness or up to a 30 day supply The Prescription Plus Program covers the complete cost of the medication, except the copayment. The member is responsible for the generic copayment for generic medication. The member is responsible for the brand copayment for brand name agents single source drugs, and the Florida Negative Formulary prescriptions. The copayment due is based on the prescription as filled, not as prescribed. In situations where the complete cost of the drug is less than the copayment, the member is responsible for the full cost of the medication to be paid to the pharmacy at the time of purchase (6) Exclusions & Limitations Medications available without a prescription or where there is a non prescription equivalent available. Oral contraceptives unless specifically listed on AV MED benefit description Blood or plasma Therapeutic devices or appliances Support garments and other medical or nonmedical supplies Prescription medications which may be properly received under local, state or federal programs including Worker's Compensation. Specific F c unions Include Devices and Drecsuigs Diaphragms Drugs or medications which do not require a prescription or a non prescription egivalent is available Fertility drugs fluoride products and prescription vitamins except prenatal vitamins Immunization drugs Immunosuppressants Injectable drug products except when administered and billed to AV MED by a physician (except msuhn, and chemotherapeutic drugs) Investigational and experimental drugs Minoxidil lotion NetAles and syringes except for insulin needles and syringes Nicorettes and other nicotine suppressants Oral contraceptives, unless the optional benefit listed above is specifically selected Prescription drugs when ordered from a government (local, State or Federal) funded program mcludmg worker's compensation Preventive fluoride medication Prescription weight suppressants Prescription and over the -counter vitamins Support garments and similar medical or non medical supplies Therapeutic devices or appliances Transdermal scolamme for recreational use a�r_ri nn_nvi /i 7_Qi 1 OF 2 6/91 AC REED TO AND ACCEPTED by the ptrttec hereto effect»c for the contract term of May 1, 1993 to May 1 19 94 Subscribing group VILLAGE OF KEY BISCAYNE AV MED INC By By Signature Rafael T Rodriguez Dame Tame Title Director of Marketing Date Data Tide AV G100-RX7/12 91 20F2 6/91 Attachment C AV-MED Health Plan Mental Health (High Option) if selected for an additional premium the following coverage is provided s Inpatient Inpatient treatment of mental and nervous disorders fore aup to memberirty is admday to contract year shall be provided at full coverage a Plan Hospital or other affiliated Health Care Facility as a registered bed member Partial During any contract year the total benefits paid by) y the ays Plan n for otient partial hospitalization for Hosprtaitzation shall names eed c services eprevailing tI ercmmmuunity where of thirty provided including physician fees Outpatient Outpatient treatment paid by the Plan shall be limited to a $1 000 maximum per contract year AGREED TO AND ACCEP ILO BY the parties the day and year hereinafter wntten Subscribing Group By VILLAGE OF KEY BISCAYNE AV MED inc d/bla AV-MED Health Plan By signature 5rgnature Name Name Title Tide Date 0 If rejected check box AV-G1PndiMA14C-738 Signature Date Date 7188(1 91) Attachment F AV-MED Health Plan Alcohol & Drug If selected for an additional premium the following coverage is provided_ Inpatient or outpatient benefits shall include intensive treatment for alcoholism and drug dependency shall not exceed a lifetime benefit of $2.000 per00it nor a maximumcation shaof llll not outpatient be provided and the cost to Health Plan shalt not exceed $3500 p under the outpatient program These benefits shall be covered only if treatment rs provided by or under the supervision of or is prescribed by Plan Physician or Plan psychologist in a program accredited by the Joint Commission on Accreditation of Hospitals or a program approved by the State of Fonda AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written Subscribing Group VILLAGE OF KEY BISCAYNE AV-MED Inc. dfbfa AV-MED Health Plan By BY sgnahne Name Date Ttle 5gnairre Name Date. Title © If rejected, check box X Signature AV -6100 -AD -F -S8 Date 7J88(1 91) AV-MED Health Plan Pregnancy - (Elective Termination) (High Option) If selected the following coverage is hereby provided This endorsement modifies Section 1239 of the AV MED Group Medical and Hospital Service Contract as follows Elective termination of pregnancy will be a covered benefit if the services and treatment are provided by an AV MED participating provider in an AV MED participating facility Them shall be a physician copayment of $100 00 AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written 1 Subscnbing group VILLAGE OF KEY BISCAYNE AV MED Inc d/b/a/ AV-MED Health Plan By By Signature 1 Rafael T Rodriguez Name Name Tide Director of Marketing Date Date 0 if rejected check box Alt -G100 -HP -88 Title Signature Date T/88(1 91) MP 1345 (4/92) AV-MED, Inc d/b/a AV-MED Health Plan Group Medical and Hospital Service Contract Master Application 04515-001 Contract Number(s) Subscnber Group Name Effective Date VILLAGE OF KEY BISCAYNE MAY 1 1993 Coverage Group Contract This Group Contract provides the benefits checked below' Schedule of Basic Benefits (including emergency inpatient hospital ambulatory diagnostic treatment and preventive health care) Check only one High Option Exhibit 1 High Option Conversion - Exhibit 1 Standard Option - Exhibit 1 Standard Option Conversion - Exhibit 1 (x) (x) () 1f selected the following optional and supplemental coverage is also provided as described in the endorsement nders to this contract Check only one - Form AV -G100 -H-88 Form AV C100 -H-88 - Form AV -G100 -S-88 Form AV -C100 -S-88 Prescnption ($64 Copay) - Form AV-6100-RX64-88 Prescnption Plus - Form AV-G100-RX3/5-88 Check only one Vision Plus - Form AV -G100 -V1-88 Vision ($5 Copay) - Form AV -6100-V2-88 Check only one Dental - ADP (Mandatory) - Form ADP -M-88 Dental - ADP (Optional) - Form ADP 0-88 (Alt dental plans are administered by Amencan Dental Plan) Check one or more Mental Health () Form AV-G100-H-MH-A-88 () Form AV-G100-S-MH-S-88 (x) Form AV-6100-H-MH-C-88 (x) Check, if Rejected () Form AV-6100-S-MH-D-88 ( ) Check, if Rejected Alcohol & Drug (x) Form AV G100 -AD -E-88 (x) Form AV G100 -AD -F-88 (x) Check rf Rejected Durable Medical Equipment (DME) () Form AV-6100-DME-88 Prosthetic Devices ( ) Form AV -G100 -PD -88 AV' C1 n(L_RR 7/88(1191) Check one or more Pregnancy (Elective Termination) (X) Form AV -6100 -H -P-88 ( ) Form AV -G100 -S -P 88 Other (X) RX$7/12 Form All-C100-RX7/12-91 ( ) Form ( ) - Form ( ) Form Eligibility A full time employee of the Subscribing Group must be employed a minimum of 30 hours per week to become eligible for coverage under this Contract A full-time employee becomes eligible for coverage under this Contract (Check and/or fill in as appropriate) () () 00 () on date of hire consecutive days after the date of hire on the first day of the month following 9 0 consecutive days after the day of hire other Termination Termination of employee coverage under this Contract shall become effective () (4 () () on the date the employees employment is terminated on the last date of the month in which the employees employment is terminated on the date the Group Contract is terminated other Agreement This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital sennces and the monthly prepaymentsubscnption charges and the mutual promises and benefits between AV-MED Inc. d/b/a AV-MED Health Plan and the Subscnbing Group This Contract shall remain in effect for a penod of twelve (12) months from the effective date of May 1 19 9 3 and may be renewed annually not later than the anniversary date upon mutual agreement of the parties The -Contract penod beg inset 12_01 ant Eastern Standard Time on the effective dateoron the anniversary date, if a renewal This Contract shall be governed by Chapter 641 Honda Statutes and other applicable State and Federal laws. The first monthly payment is due on May 1, 199 3 Subsequent payments are due on the 1st: day of each month thereafter Alf -6101548 7/86(1191)