HomeMy Public PortalAboutAgreement 05-01-05 - 04-30-06VILLAGE OF KEY BISCAYNE
Department of Finance and Administrative Services
Village Council
Robert Oldakowski Mayor
Robert L Vernon Vice Mayor
Enrique Garcia
Steve Liedman
Jorge E Mendia
Thomas Thornton
Patricia Weinman
Blanca Hernandez
Account Services Representative
AvMed Health Plan
9400 South Dadeland Blvd
Miami, Florida 33156
Dear Blanca
August 16, 2005
We are returning herewith an executed copy of our AvMed Group Medical and Hospital
Service contract for your records
Thank you
cpg
enclosure
Very t ly yours,
(///
£J2
Carolyn P Greaves
Human Resources Manager
88 West McIntyre Street • Key Biscayne, Florida 33149 • (305) 365 8904 • Fax (305) 365 8936
MISSION STATFMI NT TO PROVIDE A SAFE QUALITY COMMUNITY ENVIRONMFNT FOR ALL ISLANDERS 1 }TROUGH REST ONSIBLE GOVERNMENT
www keybiscayne fl got)
AVMED
HEALTH PLANS
August 12, 2005
Ms Carolyn P Greaves
Village of Key Biscayne
88 West McIntyre Street
Miami, FL 33149
Re Village of Key Biscayne
AvMed Group Numbers 004515
Contract Effective Date May 1, 2005
Dear Ms Greaves
9400 SOUTH DADELAND BLVD
MIAMI, FLORIDA 33156
(305) 671-5437
FLORIDA WATS 1-800-432-6676
U S WATS 1400-228-0660
Please find enclosed two copies of the AvMed Group Medical and Hospital Service Contract
AvMed is required to provide a group contract to all subscribing groups at the time of renewal
Please return one entire signed original contract to AvMed in the enclosed business reply
envelope
If we do not receive a signed contract back from you, all conditions of the enclosed contract will
still apply effective with your contract renewal date
If you have any questions, please feel free to give me a call at 305-671-6170
Best regards,
lanca Herfan`
Account Service'epresentative
AvMed Health Plan
BH pr
Enclosures
AVMED - THE HEALTH IMPROVEMENT COMPANY
MP 3473 (11/03)
AvMed Health Plans
Group Medical
and
Hospital
Service
Contract
AV -0100-2004
MP 3533 (10/04)
1
TABLE OF CONTENTS
SERVICE AREAS 1
I GENERAL 1
II INTERPRETATION 1
III DEFINITIONS 2
IV ELIGIBILITY 9
V ENROLLMENT 11
VI EFFECTIVE DATE OF MEMBERSHIP 12
VII MONTHLY PAYMENTS AND CO -PAYMENTS 13
VIII CONVERSION 14
IX TERMINATION 16
X SCHEDULE OF BASIC BENEFITS 24
XI LIMITATIONS OF BASIC BENEFITS 31
XII EXCLUSIONS FROM BASIC BENEFITS 33
XIII COORDINATION OF BENEFITS 37
XIV REIMBURSEMENT 40
XV DISCLAIMER OF LIABILITY 40
XVI GRIEVANCE PROCEDURE 41
XVII MISCELLANEOUS 48
1
AV -0100-2004
MP 3533 (10104)
AvMed CORPORATE OFFICE
9400 S DADELAND BLVD
P O BOX 569004
MIAMI, FL 33156-9004
SERVICE AREAS
MIAMI
9400 South Dadeland Boulevard
Post Office Box 569004
Miami, Florida 33156-9004
(305) 671-5437
(800) 432-6676
FT LAUDERDALE
13450 W Sunrise Boulevard
Suite 370
Sunnse, Flonda 33323-2947
(954) 462-2520
(800) 368-9189
JACKSONVILLE
1300 Riverplace Boulevard
Suite 200
Jacksonville, Florida 32207
(904) 858-1300
(800) 227-4184
GAINESVILLE
4300 N W 89th Boulevard
Post Office Box 749
Gamesville, Flonda 32606-0749
(352) 372-8400
(800) 346-0231
ORLANDO
541 South Orlando Avenue
Suite 205
Maitland, Florida 32751
(407) 539-0007
(800) 227-4848
TAMPA BAY/ SOUTHWEST FLORIDA
1511 North Westshore Boulevard
Suite 700
Tampa, Flonda 33607
(813) 281-5650
(800) 257-2273
AVMED MEMBER SERVICES - ALL AREAS
1-800-88 AVMED
(1-800-882-8633)
1
AV -0100-2004
MP 3533 (10/'04)
AvMed, INC
D/B/A AvMed HEALTH PLAN
GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT
IN CONSIDERATION of the payment of monthly prepayment subscnption charges as provided herein
and of mutual promises and benefits hereinafter descnbed, AvMed, Inc , a Florida corporation, d/b/a
AvMed Health Plans, (heremafter referred to as "Health Plan"), and
(heremafter referred to as "Subscnbmg Group") agree as follows
1 GENERAL
The Subscnbmg Group engages Health Plan to arrange for the provision of Medical Services or benefits
which are Medically Necessary for the diagnosis and treatment of Members of the Subscnbmg Group
through a network of contracted mdependent Physicians and Hospitals and other independent health care
providers, who are not agents or employees of the Health Plan (see Section 15 04) The Health Plan, m so
arranging for the delivery of Medical Services or benefits, does not directly provide these Medical
Services or benefits Health Plan arranges for the provision of said services m accordance with the
covenants and conditions contained m this Contract Health Plan shall rely upon the statements of the
Subscnber m his application m providing coverage and benefits hereunder
This Contract is not mtended 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 The deternunation as to which
services are Medically Necessary shall be made by Health Plan subject to the terms and conditions of this
Contract
Health Plan reserves the nght to make changes in coverage cntena for covered products and services
Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and
services and are based on mdependent clnucal practice guidelines and standards of care established by
government agencies and medical/pharmaceutical societies
The Medical and Hospital Services covered by this Contract shall be provided without regard to the race,
color, religion, physical handicap, or national ongm of the Member m the diagnosis and treatment of
patients, in the use of equipment and other facilities, or m the assignment of personnel to provide
services, pursuant to the provisions of Title VI of the Civil Rights Act of 1964, as amended, and the
Americans with Disabilities Act of 1990
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 mterpretation of this Contract
shall be guided by the direct service nature of the Health Plan's program and the definitions and other
provisions contained herem
1
AV -6100 2004
III DEFINITIONS
As used m this Contract, each of the following terms shall have the meaning indicated
3 01 "Adverse Benefit Determination" means a denial, reduction, or termination of, or a failure to
provide or make payment, in whole or m part, for a benefit, mcludmg any such denial, reduction,
termination, or failure to provide or make payment that is based on a determination of a
Member's eligibility to participate m the Health Plan, a denial, reduction, or termination of, or a
failure to provide or make payment (m whole or m part) of, a benefit resultmg from the
application of any Utihzation Management Program, as well as a failure to cover an item or
service for which benefits are otherwise provided because it is determined to be Experimental
and/or Investigational or not Medically Necessary
3 02 "AvMed, Inc" otherwise known as "Health Plan" means a private, not for profit Flonda
corporation, state licensed as a health maintenance organization under Chapter 641, Florida
Statutes, for the purpose of arranging for prepaid health care services to its Members under the
terms and conditions set forth in this Contract
3 03 "Claim" means a request for benefits under the Health Plan made by a Member m accordance
with the Health Plan's procedures for filmg benefit claims, mcluding Pre -Service Claims and
Post -Service Claims
3 04 "Claimant" means a Member or a Member's authorized representative actmg on behalf of the
Member The Health Plan may establish procedures for determining whether an mdividual is
authorized to act on behalf of the Member If the Claim is an Urgent Care or Pre -Service Claim,
a Health Professional, with knowledge of the Member's medical condition, shall be permitted to
act as the Member's authonzed representative and will be notified of all approvals on the
Claimant's behalf In the event of an adverse benefit determination, AvMed will notify both the
Member and the Heath Professional
3 05 "Concurrent Care" means an ongomg course of treatment to be provided over a penod of time
or number of treatments that AvMed previously approved
3 06 "Contract" means this Group Medical and Hospital Service Contract which may at times be
referred to as "Group Contract" and all applications, rate letters, face sheets, nders, amendments,
addenda, exhibits, supplemental agreements, and schedules which are or may be mcorporated m
this Contract from time to time
3 07 "Contract Year" means the penod of twelve (12) consecutive months commencmg on the
effective date of this Contract
3 08 "Conversion Contract" means an mdividual Member or Subscriber Contract which shall be
available to contmue coverage (as provided for therein) of the Subscnber or the Dependent of the
Subscnber upon termination of the Subscnbmg Group Contract as provided m Part VIII of this
Contract, and shall at times be referred to as the "Individual" or "Conversion Contract "
2
AV -G100 2004
3 09 "Co -payment" means the charge, m 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 Co -payment may be a specific dollar amount or a percentage of the cost The covered
Subscnber/Member is responsible for the payment of any Co -payment charges directly to the
provider of the health services at the time of service
3 10 "Custodial Care" means services and supplies that are furnished mainly to train or assist m the
activities of daily living, such as bathmg, feeding, dressmg, 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 dressmg changes and catheter care
or that ambulatory patients customanly provide for themselves, such as ostomy care, measunng
and recordmg urine and blood sugar levels, and administermg msulm
3 11 "Dental Care" means dental x-rays, examinations and treatment of the teeth or structures directly
supportmg the teeth that are customanly provided by dentists, mcludmg orthodontics,
reconstructive jaw surgery, casts, splints, and services for dental malocclusion
3 12 "Dependent" means any Member of a Subscnber's family who meets all apphcable 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 13 "Durable Medical Equipment (DME), Orthotics, and/or Prosthetics" Coverage for DME,
Orthotics and Prosthetics is limited as outlined m Section(s) 10 20 and 10 21 subject to specific
Limitations and Exclusions as listed m Part XII The determination of whether a covered item
will be paid under the DME, Orthotics or Prosthetics benefit will be based upon its classification
as defined by the Centers for Medicare and Medicaid Services
3 14 "Emergency Medical Condition" means
3 14 01
A medical condition manifestmg itself by acute symptoms of sufficient seventy such
that the absence of immediate medical attention could reasonably be expected to
result m any of the followmg
a) Serious jeopardy to the health of a patient, mcludmg a pregnant woman or fetus
b) Serious impairment to bodily functions
c) Senous dysfunction of any bodily organ or part
3 14 02 With respect to a pregnant woman
a) That there is inadequate time to effect safe transfer to another Hospital pnor to
delivery,
b) That a transfer may pose a threat to the health and safety of the patient or fetus
or
3
AV -G100 2004
c) That there is evidence of the onset and persistence of utenne contractions or
rupture of the membranes
3 14 03
Examples of Emergency Medical Conditions include, but are not limited to heart
attack, stroke, massive mternal or external bleeding, fractured limbs, or severe
trauma
3 15 "Emergency Medical Services and Care" means medical screening, examination, and
evaluation by a Physician, or, to the extent permitted by applicable law, by other appropnate
personnel under the supervision of a Physician, to determine if an Emergency Medical Condition
exists and, if it does, the care, treatment, or surgery for a covered service by a Physician
necessary to relieve or eliminate the Emergency Medical Condition withm the service capability
of the Hospital
3 1501
3 15 02
In -Area Emergency does not mclude elective or routme care, care of Honor illness, or
care that can reasonably be sought and obtained from the Member's Pnmary Care
Physician The determination as to whether or not an illness or mjury constitutes an
emergency shall be made by Health Plan and may be made retrospectively based
upon all mformation known at the time patient was present for treatment
Out -of -Area Emergency does not mclude care for conditions for which a Member
could reasonably have foreseen the need of such care before leavmg the Service Area
or care that could safely be delayed until prompt return to the Service Area The
determination as to whether or not an illness or mjury constitutes an emergency shall
be made by Health Plan and may be made retrospectively based upon all mformation
known at the time patient was present for treatment
3 16 "Exclusion" means any provision of this Contract whereby coverage for a specific hazard or
condition is entirely eliminated
3 17 "Full -Time Student" means one who is attending a recognized and/or accredited college,
university, vocational, or secondary school and is carrymg sufficient credits to qualify as a Full -
Time Student m accordance with the requirements of the school (See Subsection 4 02 02(0)
3 18 "Group Health Insurance" (for purposes of Part XIII) means that form of health insurance
covering groups of persons under a master Group Health Insurance policy issued to any one of
the groups listed m Sections 627 552 (employee groups), 627 553 (debtor groups), 627 554 (labor
union and association groups), and 627 5565 (additional groups), Flonda Statutes
3 18 01 The terms "amount of insurance" and "msurance" mclude the benefits provided under
a plan of self-msurance
3 18 02 The term "msurer" includes any person, entity, or governmental unit providmg a plan
of self-msurance
3 18 03 The terms "policy," "msurance policy," "health msurance policy," and "Group Health
Insurance policy" mclude plans of self-msurance providmg health msurance benefits
4
AV -6100 2004
3 19 "Health Plan" means AvMed, Inc , a not for profit Flonda corporation, d/b/a AvMed Health
Plan, which has been certified as a health maintenance organization by the Department of
Insurance of the State of Florida to arrange for provision by the plan of prepaid health benefits
and services covered by this Contract
3 20 "Health Professionals" means Physicians, osteopaths, podiatrists, chiropractors, Physician
assistants, nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists,
occupational therapists, physical therapists, and other professionals engaged m the delivery of
health care services who are licensed and practice under an mstitutional license, mdividual
practice association, or other authonty consistent with state law and who are Participating
Providers of Health Plan
3 21 "Home Health Care Services" means services that are provided for a Member who is
homebound and who does not require confinement m a Hospital or Other Health Care Facility
Such services mclude, but are not limited to, the services of professional visiting nurses or other
health care personnel for services covered under this Contract See Section 11 11 regarding
Physical and Occupational Therapy Limitations
3 22 "Hospice" means a pubhc agency or pnvate organization which is duly licensed by the State to
provide Hospice services and with whom Health Plan has a current provider agreement Such
licensed entity must be pnncipally engaged m providing pain relief, symptom management, and
supportive services to terminally ill Members
3 23 "Hospital" means any general acute care facility which is licensed by the state and with which
Health Plan has contracted or established arrangements for mpatient Hospital Services and/or
Emergency Services, and shall at times be referred to as "Participatmg Hospital "
3 24 "Hospital Services" (except as expressly limited or excluded by this Contract) means those
services for registered bed patients which are
3 24 01 Generally and customarily provided by acute care general Hospitals within the
Service Area,
3 24 02 Performed, prescnbed, or directed by Participating Providers, and
3 24 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
3 25 "Hospitalist/Admitting Panelist" means a Physician who specializes in treating inpatients and
who may coordinate a Member's health care when the Member has been admitted for a Medically
Necessary procedure or treatment at a Hospital
3 26 "Limitation" means any provision other than an Exclusion which restricts coverage under this
Contract
5
AV -6100 2004
3 27 "Master Application" means the Subscnbmg Group application form entitled "Master
Application" which becomes a part of the Contract when the Master Apphcation has been
completed and executed by the Subscnbmg Group and Health Plan
3 28 "Medically Necessary" means the use of any appropnate medical treatment, service, equipment,
and/or supply as provided by a Hospital, skilled nursmg facility, Physician, or other provider
which is necessary for the diagnosis, care, and/or treatment of a Member's illness or injury, and
which is
3 28 01 Consistent with the symptom, diagnosis, and treatment of the Member's condition,
3 28 02 The most appropriate level of supply and/or service for the diagnosis and treatment of
the Member's condition,
3 28 03 In accordance with standards of acceptable community practice,
3 28 04 Not pnmanly mtended for the personal comfort or convenience of the Member, the
Member's family, the Physician, or other health care provider,
3 28 05 Approved by the appropriate medical body or health care specialty involved as
effective, appropriate, and essential for the care and treatment of the Member's
condition,
3 28 06 Prescnbed, directed, authonzed, and/or rendered by a participatmg or authonzed
provider, except in the case of an emergency, and
3 28 07 Not experimental or mvestigational
3 29 "Medical Office" means any outpatient facility or Physician's office m the Service Area utilized
by a Participatmg Provider
3 30 "Medical Services" (except as limited or excluded by this Contract) means those professional
services of Physicians and other Health Professionals mcludmg medical, surgical, diagnostic,
therapeutic, and preventive services which are
3 30 01 Generally and customanly provided m the Service Area,
3 30 02 Performed, prescnbed, or directed by Participatmg Providers, and
3 30 03 Medically Necessary (except for preventive services as stated herem) for the
diagnosis and treatment of injury or illness
3 31 "Member" means any Subscnber or Dependent, as descnbed m Part III, Sections 3 12 and 3 42
of this Contract
6
AV -G100 2004
3 32 "Non -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 neither
made arrangements nor contracted to render the professional health services set forth herem
3 33 "Other Health Care Facility(ies)" means any hcensed facility, other than acute care Hospitals
and those facihties providing services to ventilator dependent patients, providing inpatient
services such as skilled nursmg care or rehabilitative services for which Health Plan has
contracted or established arrangements for providing these services to Members Coverage is
lmuted to 20 days per Calendar Year
3 34 "Participating Provider" means any Health Professional or group of Health Professionals or
Hospital, Medical Office, or Other Health Care Facihty with whom Health Plan has made
arrangements or contracted to render the professional health services set forth herem
3 35 "Participating Physician" means any participatmg Physician licensed under Chapter 458
(physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Flonda Statutes "Attending
Physician" means the Participating Provider Physician pnmanly responsible for the care of a
Member with respect to any particular mjury or illness
3 36 "Post -Service Claim" means any Claus for benefits under the Health Plan that is not a Pre -
Service Clain
3 37 "Pre -Service Claim" means any Claim for benefits under the Health Plan with respect to which,
m whole or m part, a Member must obtain authonzation from AvMed m advance of such services
bemg provided to or received by the Member
3 38 "Primary Care Physician" means a Participating Provider Physician engaged m family practice,
pediatrics, mtemal medicine, obstetrics/gynecology, or any specialty Physician from time to time
designated by Health Plan as "Primary Care Physician" m Health Plan's current list of Physicians
and Hospitals
3 39 "Relevant Document" means any documentation that
3 39 01 Was rehed upon in making the benefit determination,
3 39 02 Was submitted, considered or generated m the course of making the benefit
determination, without regard to whether it was rehed upon m making the
determination,
3 39 03 Demonstrates comphance with the administrative process, and
3 39 04 Constitutes a statement of policy or guidance with respect to the Health Plan concerning
the Adverse Benefit Determination for the Claimant's diagnosis, without regard to
whether such advice or statement was rehed upon m making the Adverse Benefit
Determination
7
AV -6100 2004
3 40 "Service Area" means those counties m the State of Flonda where AvMed has been approved to
conduct busmess by the Flonda Department of Financial Services
3 41 "Specialty Health Care Physician" means any participating physician licensed under Chapter
458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Flonda Statutes, other
than the Member's chosen Primary Care Physician
3 42 "Subscriber" means a person who meets all applicable requirements of Part IV, enrolls m Health
Plan, and for whom the premium prepayment required by Part VII has actually been received by
Health Plan
3 43 "Subscribing Group" means an employer who negotiates and agrees to contract for the health
services and benefits provided herem for its eligible employees, and shall at times be referred to
herem as "Employer" or "Contract Holder "
3 44 "Total Disability" means a totally disabling condition resulting from an illness or mjury which
prevents the Member or Subscriber from engaging in any employment or occupation for which he
may otherwise become qualified by reason of education, training, or experience, and for which
the Member or Subscnber is under the regular care of a Physician
3 45 "Urgent Care Claim" means any Clain for medical care or treatment that could seriously
jeopardize the Member's life or health or the Member's ability to regam maxunum function or, m
the opinion of a Physician with knowledge of the Member's medical condition, would subject the
Member to severe pain that cannot be adequately managed without the care or treatment
requested Generally, the determination of whether a Claim is an Urgent Care Claim shall be
made by an mdividual actmg on behalf of the Health Plan applying the judgment of a prudent
layperson who possesses an average knowledge of health and medicme However, if a Physician
with knowledge of the Member's medical condition determines that the Claim is an Urgent Care
Claim, it shall be deemed as such
3 46 "Urgent Care/Immediate Care" means medical screening, examination, and evaluation
received m an Urgent Care Center or Immediate Care Center or rendered in your Primary Care
Physician's office after-hours and the covered services for those conditions which, although not
life -threatening, could result in serious mjury or disabihty if left untreated
3 47 "Utilization Management Program" means those procedures adopted by Health Plan to assure
that the supplies and services provided to Members are Medically Necessary These mclude, but
are not limited to (1) pre-authonzation for specialty referrals, Hospital admissions (except
emergencies), outpatient surgery, and certain outpatient diagnostic tests and procedures, (2)
concurrent review of all patients hospitalized m acute care, psychiatric, rehabihtation, and skilled
nursing facilities, mcludmg on -site review when appropnate, (3) case management and discharge
planning for all mpatients and those requiring contmued care m an alternative settmg (such as
homecare or a skilled nursmg facility) and for outpatients when deemed appropnate
8
AV -G100 2004
3 48 "Ventilator Dependent Care Unit" means care received in any facility which provides services
to ventilator dependent patients other than acute Hospital care, mcluding all types of facilities
known as sub -acute care units, ventilator dependent units, alternative care units, sub -acute care
centers, and all other like facilities whether maintained m a free standing facihty or maintained m
a Hospital or skilled nursmg facihty settmg Coverage is hunted to 100 days lifetime maximum
IV ELIGIBILITY
4 01 To be eligible to enroll as a Subscnber, a person must be
4 01 01
An employee of the Subscnbmg Group who works the required number of hours per
week as set forth in the Master Application for this Contract The employee must
either work or reside m the Service Area Except as provided for Emergency
Services, the covered services and benefits are available only from Participating
Providers
4 01 02 Employed for the penod of time required for eligibility as set forth m the Master
Application, and
4 01 03 Entitled on his own behalf to participate m the medical and Hospital care benefits
arranged by the Subscnbmg Group under this Contract
4 02 To be eligible to enroll as a Dependent, a person must be
4 02 01 the spouse of the Subscnber, a new spouse must be enrolled within thirty-one (31)
days after marriage m order to be covered, or
4 02 02 a child of the Subscnber, or a child of a covered Dependent of the Subscnber,
provided that the following conditions apply
a) The child is the natural child or stepchild of the Subscriber, a legally adopted
child m the custody of the Subscnber from the time of placement m the home
(written evidence of adoption must be furnished to Health Plan upon request), a
child for whom the Subscnber is permanent legal guardian, or a newborn child of
a covered Dependent of the Subscriber (such coverage terminates 18 months after
the birth of the newborn child),
b) The child resides with the Subscnber (except for "f' and "h" below),
c) The child is under the age of 19 (except for "f' and "g" below or Section 4 04
below),
d) The child is principally dependent upon the Subscnber for maintenance and
support and is not regularly employed by one or more employers for a total of
thirty (30) hours or more per week,
e) The child is not marred,
AV -G100 2004
9
f) The child is age 19 or over but under the age of 23, or other hmitmg age as
specified by the parties m a fully executed addendum to this Contract, and is
enrolled as a Full -Tune Student (See Section 3 17) at a college, university,
vocational, or secondary school Subscriber is responsible for notifymg Health
Plan when full-time attendance commences or terminates, and coverage shall
commence or terminate upon such notification Ceasmg of coverage will be
retroactively applied if Health Plan is not notified Subscnber agrees to provide
documentation of Full -Tune Student status upon request of Health Plan,
g)
The child is age 19 or over and is wholly dependent on the Subscnber due to
mental retardation or physical handicap (See Section 4 04)
h) In the event an eligible Dependent child does not reside with the Subscriber,
coverage will be extended where the Subscriber is obhgated to provide medical
care by Quahfied Medical Support Order provided the ehgible Dependent resides
within the Service Area You (or your beneficiaries) may obtam, without charge,
copies of the Plan's procedures governing qualified medical support orders and a
sample qualified medical support order by contactmg the Plan Administrator
i) In the case of a newborn child, Health Plan should be notified m wnting pnor to
the scheduled delivery date of the Subscriber's intention to enroll the newborn
child, but such notice shall not be later than thirty-one (31) days after the birth
If timely notice is provided, no additional premium will be charged for the
additional coverage of the newborn durmg the thirty-one (31) day penod
followmg the birth of the child If timely notice is not provided, the additional
premium for the additional coverage of the newborn child will be charged from
the child's date of birth If notice is not provided within 60 days of the birth, the
child may not be enrolled until the next open enrollment penod of the
Subscnbmg Group
All services applicable for covered Dependent children under this Contract shall
be provided to an enrolled newborn child of the Subscnber or to the enrolled
newborn child of a covered Dependent of the Subscnber or to the newborn
adopted child of the Subscriber provided that a written agreement to adopt such
child has been entered into (pnor to the birth of the child) from the moment of
birth (as provided m Part X, Section 10 11) In the case of the newborn adopted
child, however, coverage shall not be effective if the child is not ultimately
placed m the Subscnber's residence m comphance with Florida law
Coverage for the newborn child of a covered Dependent of the Subscriber (other
than the spouse of the Subscriber) shall terminate eighteen (18) months after the
birth of the newborn child
4 03 No person is ehgible to enroll hereunder who has had his coverage previously terminated under
Part IX, Subsection 9 01 05, except with the written approval of Health Plan
10
AV -G100 2004
4 04 Attainment of the limitmg age by a Dependent child shall not operate to exclude from or
terminate the coverage of such child nor shall coverage 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 Subscnber for support and mamtenance, provided proof
of such mcapacity and dependency is furnished to Health Plan by Subscriber within
thirty-one (31) 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 penod followmg the child's attainment of the limiting age
4 05 Durmg the term of this Contract, no changes m the Subsctibmg 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 Pnor to the effective date of this Contract and at a proper time pnor to each anniversary thereof,
Health Plan may allow an open enrollment penod of thirty-one (31) days, m which any ehgible
Subscnber on behalf of himself and his Dependents may elect to enroll m Health Plan
5 02 Except as provided for newborns, eligible Subscribers and Dependents who meet the
requirements of Part IV, Sections 4 01 and 4 02 must enroll within thirty-one (31) days after
becoming eligible by submittmg apphcation forms acceptable to or provided by Health Plan,
otherwise, the eligible Subscribers and Dependents may not enroll until the next open enrollment
period of Subscnbmg Group
5 03 Special Enrollment Penods An eligible Subscnber or Dependent may request to enroll under
Health Plan outside of the initial enrollment and Annual Open Enrollment Penods if that
Individual, within the immediately preceding thirty-one (31) days, was covered under another
employer health benefit plan as an employee or Dependent at the time he was initially ehgible to
enroll for coverage under Health Plan, and
5 03 01 Demonstrates that he or his Dependent has expenenced one of the followmg status
change events, mcludmg
a) mamage,
b) birth, adoption or placement for adoption,
c) legal separation, divorce or annulment,
d) change m legal custody or legal guardianship,
11
AV -G100 2004
e) death,
f) relocation mto or out of a Service Area,
g) termmation/commencement of employment,
h) reduction m the number of hours of employment,
i) commencement of or return from leave of absence,
j) change m employment status,
k) change m worksite,
1) strike or lockout,
m) termination of coverage due to the termination of employer contnbutions toward
such coverage, and
5 03 02 Requests enrollment withm thirty-one (31) days after the termination of coverage
under another employer health benefit plan, and
5 03 03 Provides proof of continuous coverage under the other employer health benefit plan
5 04 The eligibility requirements set forth m Part IV shall at all tunes control and no coverage contrary
thereto shall be effective Coverage shall not be implied due to clerical or administrative errors if
such coverage would be contrary to Part IV (Also see Section 17 10)
5 05 This Contract, at the sole option of Health Plan, will not be accepted if at time of initial offering
to Subscnbmg 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 m the rate letter submitted to Subscnbmg 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 Subscnbers and Dependents who enroll during the open enrollment penod will be
covered Members as of the effective date of this Contract or subsequent anniversary thereof
6 02 If a Subscnber acquires an eligible Dependent through birth, adoption, placement for adoption or
marriage, such Dependent shall be treated as immediately covered under the Plan if, within 31
days (or as otherwise provided for newborns m Part IV) of acquiring the new Dependent, you
complete and submit an enrollment form on behalf of such Dependent If received by the Plan
withm the 31 -day tune penod (or 60 -days as permitted for newborns), the enrollment for such
12
AV -G100 2004
Dependent shall become effective on the date of the birth, adoption or placement for adoption, or
for mamage, the first day of the month followmg the date you enroll your new spouse Durmg
this penod, you and your ehgible spouse may also enroll for medical coverage under the Plan, if
not already covered However, if an enrollment is not received by the Plan within the required
tuneframe, you and your ehgible Dependents will be required to wait until the next open
enrollment period to apply for coverage
6 03 If you or your Dependents ongmally declmed medical coverage under the Plan due to other
health coverage, and that coverage is subsequently terminated as a result of either a loss of
eligibility for such coverage or the termination of any employer contributions for such coverage,
you and your Dependents will be eligible to enroll m the Plan To enroll, you must properly
complete an enrollment form withm 31 days of the loss of such other coverage or termination of
employer contributions The effective date of any coverage provided under the Plan will be the
first day of the month followmg the date you enroll If you fail to enroll withm 31 days after the
loss of other coverage, you must wait until the next open enrollment penod to apply for coverage
6 04 Coverage for the newborn child of the Subscriber or the newborn child of the Subscnber's
covered Dependent is effective at birth if Subsection 4 02 02(i) and Section 6 02 are comphed
with
VII MONTHLY PAYMENTS AND CO -PAYMENTS
7 01 On or before the first day of each month for which coverage is sought, Subscnbmg Group or its
designated agent shall remit to Health Plan, on behalf of each Subscnber and his Dependents, the
monthly premium based on the rate letter and Master Application Only Members for whom the
stipulated payment is actually received by Health Plan shall be entitled to the health services
covered under this Contract and then only for the period for which such payment is applicable
Failure of the Subscnbmg Group to pay premiums for the group by the first of the month and not
later than the end of the grace penod (as provided m Section 7 02) shall result in retroactive
termination of the group, effective at 12 00 a m (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 m a fully executed addendum to this Contract An additional
charge will apply to all late premium payments (See Section 17 14)
7 02 Grace Penod This Contract has a ten (10) day grace penod This provision means that if any
required premium is not paid on or before the date it is due, it must be paid during the followmg
grace penod During the grace period, the Contract will stay m force However, if payment is
not received by the last day of the grace penod, termination of this Contract for nonpayment of
premium will be retroactive to 12 00 a m (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
7 03 Maximum Co -payments Total annual Co payments are limited as descnbed in your Schedule of
Co -payments The Co -payment limits apply to Co -payments made for all core benefits contamed
m this Contract, and do not apply to services provided under the Prescnption Drug, Mental
Health, Substance Abuse, Vision and other supplemental nders It is the responsibility of the
13
AV -6100 2004
Subscnber/Member to retain receipts and to notify and document to the satisfaction of Health
Plan when either of the Co -payment limits has been reached
7 04 Member shall pay premiums, applicable supplemental charges, or Co -payments as provided in
this Contract If he fails to do so, upon ten (10) days written notice from Plan to Member, the
Member's nghts hereunder shall be terminated Consideration for remstatement with the Plan
shall require a new application, and any re -enrollment shall be at the sole discretion of Health
Plan and shall not be retroactive
7 05 Refund of premiums paid to Health Plan by the Subscnbmg Group for any Member after the 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 maxunum of sixty (60) days from the date of such meligibihty
or termination, provided there are no claims mcurred subsequent to the effective date of
termination
No retroactive terminations of Members will be made beyond 60 days from notification of the
termmatmg event
7 06 In the event of the retroactive termmation of an mdividual Member (as descnbed m Subsections
9 01 02 and 9 02 01 of this Contract), Health Plan shall not be responsible for medical expenses
mcurred by Health Plan m providing benefits to the Member under the terms of this Contract
after the effective date of termination (due to the Subscnbmg Group's nonpayment of premiums
or failure to timely notify the Plan of Member meligibility) At the discretion of Health Plan
based on the facts available to Health Plan at the time, Health Plan may pursue either the
Subscnbmg Group or the Member for payment
VIII CONVERSION
8 01 A Subscnber or covered Dependent whose coverage under the Subscnbmg Group Contract has
been terminated for any reason, mcludmg discontinuance of the Subscnbmg Group Contract m its
entirety or with respect to a covered class, and who has been contmuously covered under the
Subscnbmg Group Contract, and under any group health maintenance Contract providing similar
benefits which it replaces, for at least three (3) months immediately prior to termination, shall be
entitled, subject to the exceptions contained herem, to have issued to hum or her a Conversion
Contract (See Section 3 08), unless there is a replacement of discontinued group coverage by
sumlar group coverage withm thirty-one (31) days
8 01 01
The convertmg Subscriber and each of the eligible Dependents of the Subscriber who
are convertmg must be Members of the Plan m good standmg on the date when their
coverage terminates under this Group Contract, and all such Subscnbers and
Dependents, after complymg with Subsection 8 01 02 below, shall be covered under
the Individual Conversion Contract
8 01 02 A completed status change form requesting conversion shall be sent to Health Plan or
its designated administrator with the first applicable premium and shall be received
14
AV -6100 2004
by Health Plan or its designated administrator not later than sixty-three (63) days
after the date of termination of this Group Contract
8 01 03 Dependents may not convert without the Subscnber except
a) In the event of the death of the Subscriber, Dependents are permitted an
automatic conversion pnvilege and must comply with Subsection 8 01 02 above
b) A spouse whose coverage would terminate or a spouse and children whose
coverage would otherwise terminate at the same time or a child with respect to
himself, by reason of ceasmg to be a qualified family member, may convert and
must comply with Subsection 8 01 02 above
c) A former spouse whose coverage would otherwise terminate because of
annulment or dissolution of marriage may convert if the former spouse is
dependent for financial support The former spouse must comply with
Subsection 8 01 02 above and must provide wntten evidence of fmancial
dependence upon request of Health Plan
8 01 04
Payment for health care services rendered to a Member after termination and pnor to
conversion shall be the responsibility of the Member When the conversion
application has been timely completed (within sixty-three (63) days after termination
of the Group Contract) and the first premium due has been paid, Health Plan shall
reimburse the Subscnber for any payment made by the Subscnber for covered
Medical Services under the converted Contract
8 01 05 A new Conversion Contract is estabhshed upon application and payment of premium
on the day followmg the Member's termination from group coverage (due to
ineligibility under the Group Contract) and contmues through the end of the calendar
year The Contract Year, upon renewal, shall be the calendar year
8 02 Individual Conversion Contracts may not mclude supplemental benefits, notwithstanding the
supplemental benefits included under this Subscnbmg Group Contract, and may m other respects,
as determined by Health Plan, differ from this Group Contract
8 03 The conversion privilege will not apply to a Subscnber or covered Dependent if termination of
his coverage under this Contract occurred for any of the followmg reasons
8 03 01 Failure to pay any required premium or contribution unless such nonpayment of
premium was due to acts of an employer or person other than the individual,
8 03 02 Replacement of any discontmued group coverage by similar group coverage within
thirty-one (31) days,
8 03 03 Fraud or matenal misrepresentation m applymg for any benefits under this Contract,
(See Subsection 9 01 05)
15
AV -G100 2004
8 03 04 Willful and knowing misuse of Health Plan's membership identification card by the
Subscriber,
8 03 05 Willfully and knowmgly furnishing mcorrect or incomplete mformation to Health
Plan for the purpose of fraudulently obtaining coverage or benefits from Health Plan,
or
8 03 06 Termination from coverage under this Contract m accordance with Subsection
9 01 05
8 04 Conversion After Continuation Coverage When continuation coverage as provided under the
provisions of the Consolidated Omnibus Budget Reconcihation Act of 1986 (COBRA) expires,
the Subscnber or covered Dependent may be eligible for conversion coverage and may apply by
completing an application for an mdividual Conversion Contract, subject to the conditions
descnbed m Part VIII, above The eligible Subscriber or Dependent must send a completed
application and the applicable premium payment, postmarked not later than sixty-three (63) days
after the termination of COBRA coverage, directly to
AvMed Health Plans
Accounts Receivable Department
Suite 510
9400 South Dadeland Blvd
Miami, Flonda 33156
The Subscnber or Dependent may obtain an application form and a statement of current premium
rates for the mdividual Conversion Contract by callmg AvMed Member Services
It is the responsibility of the Subscribing Group to notify Subscnber of Subscnber's nghts under
COBRA For any specific questions concerning COBRA, contact the Subscnbmg Group
IX TERMINATION
All nghts and benefits under this Contract shall cease as of the effective date of termination, unless
otherwise provided herem
This Contract shall continue m effect for one year from the effective date hereof and may be renewed
from year to year thereafter, subject to the following termination provisions All nghts to benefits under
this Contract shall cease at 12 00 a m (midnight) on the effective date of termination
9 01 Reasons for Termination
9 01 01 Loss of Eligibility - Subject to the conversion rights under Section 8 04
a) Upon a loss of the Subscriber's or Dependent's eligibility as defined m Part IV,
including but not limited to the permanent relocation outside Health Plan Service
16
AV -6100 2004
Area, coverage shall automatically terminate on the last day of the month for
which the monthly premium was paid and during which the Subscnber and/or
Dependent was eligible for coverage
b) Coverage for all Dependents shall automatically terminate on the last day of the
month for which the monthly premium was paid upon a loss of the Subscnber's
eligibility, as defined m Part IV
9 01 02
9 01 03
9 01 04
AV -G100 2004
Failure to Make Premium Payment - Upon failure of the Subscnbmg Group to make
payment of the monthly premiums provided m Part VII within ten (10) days
followmg the due date specified herem, benefits hereunder shall terminate, for all
Subscnbers and any Dependents for whom such payment has not been received, at
12 00 a m (midnight), on the last day of the month for which the monthly premium
was paid
Upon failure of the Subscnber to make payment of any premium contributions or
applicable supplemental charges required by Section 7 04 of this Contract, coverage
shall automatically terminate for the Subscnber and all Dependents on the tenth day
after written notice from Health Plan
AvMed Health Plan, regarding cancellation or non -renewal of this coverage, may
retroactively cancel the policy to the date for which the employer's premiums have
been paid when AvMed provides notice of cancellation or non -renewal to the
Subscnbmg Group pnor to 45 days after the date premium was due AvMed will
mclude a reason for the Contract termination m its written notification to the
Subscnbmg Group The Subscnbmg Group will forward such notification to all
Subscribers when AvMed has notified the Subscnbmg Group of the cancellation or
non -renewal, and AvMed is deemed to have complied with its notification
requirements by providing said notice to the Subscnbmg Group
Termination of Group Contract by Subscnbmg Group - Group may terminate this
Group Contract on the anniversary date by givmg wntten notice to Health Plan
fifteen (15) days prior to Contract anniversary date In such event, benefits
hereunder shall terminate for all Members at 12 00 am (midnight) on Contract
expiration date
Termination of Group Contract by Health Plan - Health Plan may non -renew or
discontmue this Group Contract based on one or more of the followmg conditions In
such event, benefits hereunder shall terminate for all Members at 12 00 am
(midnight) on Contract expiration date as descnbed below
a) Subscnbmg Group has failed to pay premiums or contributions m accordance
with the terms of this Contract or Health Plan has not received timely premium
payments (See Part VII, Monthly Payments and Co -payments and Subsection
9 01 02) Termination of coverage will be effective on the last day of the month
for which payments were received by Health Plan
17
b) Subscnbmg Group has performed an act or practice that constitutes fraud or
made an intentional misrepresentation of matenal fact under the terms of this
Contract This will result m immediate termination of Subscnbmg Group
c) Subscnbmg Group has failed to comply with a matenal provision of the plan
which relates to rules for employer contributions or group participation
Termination will be effective upon forty-five (45) days written notice from
Health Plan to Subscnbmg Group
d) There is no longer any enrollee m connection with the plan who lives, resides, or
works in Health Plan's Service Area Termination of coverage will be effective
on the last day of the month for which payments were received by Health Plan
e) Health Plan ceases to offer coverage m the applicable market Termination will
be effective upon one -hundred and eighty (180) days wntten notice from Health
Plan to Subscnbmg Group
9 01 05
Termination of Membership for Cause - Health Plan may terminate any Member
immediately upon written notice for the following reasons which lead to a loss of
eligibility of the Member
a) fraud, matenal misrepresentation, or omission m applymg for membership,
benefits, or coverage under this Contract However, relative to a misstatement m
the Apphcation, after two (2) years from the issue date, only fraudulent
misstatements m the Application may be used to void the policy or deny any
claim for a loss occurred or disability startmg after the two (2) year penod,
b) misuse of Health Plan's Membership Card furnished to the Member,
c) furmshmg to Health Plan mcorrect or incomplete mformation for the purpose of
obtammg Membership, coverage, or benefits under this Contract,
d) behavior which is disruptive, unruly, abusive, or uncooperative to the extent that
the Member's contmumg coverage under this Contract senously impairs the
Health Plan's ability to administer this Contract or to arrange for the delivery of
health care services to the Member or other Members after Health Plan has
attempted to resolve the Member's problem
At the effective date of such termination, premium payments received by Health
Plan on account of such termination shall be refunded on a pro rata basis, and
Health Plan shall have no further liability or responsibility for the Member(s)
under this Contract
9 02 Notification Requirements
9 02 01 Loss of eligibihty of Subscnber - It is the responsibility of Subscnbmg Group to
notify Health Plan m wntmg withm thirty-one (31) days from the effective date of
18
AV -G100 2004
termination regarding any Subscnber and/or Dependent who becomes meligible to
participate in Health Plan Failure of the Subscnbmg Group to provide timely
written notice as described above may lead to retroactive termination of the
Subscriber and/or Dependent The effective date for such retroactive termination will
be the last day of the month for which premium was paid and during which the
Subscnber and/or Dependent was eligible for coverage (See Section 7 06)
9 02 02 Loss of eligibility of Dependent - When a Dependent becomes ineligible for
Dependent coverage, the Subscriber is required to notify Health Plan m wnting
within thirty-one (31) days of the Dependent becoming meligible
9 02 03 Contract Termination - In the event this Contract is terminated, the Subscnbmg
Group agrees that it shall provide forty-five (45) days pnor wntten notification of the
date of such termination to its employee Subscnbers who are covered under this
Contract
In no event will any retroactive termination of a Member be made beyond 60 days from
notification of the tenminatmg event
9 03 Certificates of Coverage If your coverage under the Plan ends, you will automatically receive a
Certificate of Group Health Plan Coverage You may take this certificate to another health care
plan to receive credit for your coverage under the Plan You will only need to do this if the other
health care plan has a pre-existing condition limit You can request a Certificate of Group Health
Plan Coverage anytime during the 24 -month period after the date your coverage under the Plan
has ended
9 04 Contmuation Coverage under COBRA Under certain provisions of the Consolidated Omnibus
Budget Reconciliation Act of 1986 (COBRA), the Subscriber or his Dependent(s) may elect
continued coverage under the Plan, if coverage is lost due to a quahfymg event
9 04 01 Ehgibility You or your covered Dependents will become eligible for continuation
coverage under the Consolidated Omnibus Reconciliation Act of 1986, as amended
(COBRA) after any of the following qualifying events result m the loss of plan
coverage
a) loss of benefits due to a reduction in your hours of employment,
b) termination of your employment, mcludmg retirement but excluding termination for
gross misconduct,
c) termination of employment following FMLA leave, m which case the qualifying
event will occur on the earlier of the date you indicated you were not returning to
work or the last day of the FMLA leave, or
d) you or a Dependent first become entitled to Medicare or covered under another group
health plan pnor to your loss of coverage due to tennination of employment or
reduction in hours
19
AV -G100 2004
9 04 02 In addition, your enrolled Dependents will become eligible for COBRA continuation
coverage after any of the followmg qualifymg events occur to cause a loss of plan
coverage
a) your death,
b) your divorce or legal separation,
c) you first become entitled to Medicare after your loss of coverage due to
termmation of employment or reduction m hours, or
d) your Dependent child no longer qualifies as a Dependent under the plan
A child who is born to or placed for adoption with a covered former employee dunng
the contmuation coverage penod has the same contmuation coverage nghts as a
Dependent child descnbed above
9 04 03 Notification If a qualifymg event other than divorce, legal separation, loss of
Dependent status or entitlement to Medicare occurs, the plan administrator will be
notified of the qualifying event by your employer and will send you an election form
To contmue plan coverage, you must return the election form withm 60 days from
the later of the date you receive the form, or the date your coverage ends due to a
quahfymg event
If divorce, legal separation, loss of Dependent status or entitlement to Medicare
under the plan occurs, you or your covered Dependent must notify the plan
adnmstrator that a qualifying event has occurred This notification must be received
by the plan administrator withm 60 days after the later of the date of such event, or
the date you or your eligible Dependent would lose coverage on account of such
event Failure to promptly notify the plan administrator of these events will result in
loss of the nght to continue coverage for you and your Dependents
After receivmg this notice, the plan administrator will send you an election form
withm 14 days If you or your Dependents wish to elect contmuation coverage, the
election form must be returned to the plan admunistrator withm 60 days from the later
of the date you receive the form, or the date your coverage ends due to the quahfymg
event
9 04 04 Cost If you elect to continue coverage, you must pay the entire cost of coverage (the
employer's contribution and the active employee portion of the contribution), plus a
2% admumstrative fee for the duration of COBRA contmuation coverage
If you or your Dependent is Social Secunty disabled (Social Security disabihty status
must occur as defined by Title II or Title XVI of the Social Security Act), you may
elect to contmue coverage for the disabled person only or for some or all of COBRA
eligible family members for up to 29 months if your employment is terminated or
20
AV -G100 2004
your hours are reduced You must pay 102% of the cost of coverage for the first 18
months of COBRA contmuation coverage and 150% of the cost of coverage for the
19th through the 29th months of coverage The Social Security disability date must
occur withm the first 60 days of loss of coverage due to your termination of
employment or reduction m hours
For COBRA coverage to remam m effect, payment must be received by the plan
adrmistrator by the first day of the month for which the premium is due (Your first
payment is due no later than 45 days after your election to contmue coverage, and it
must cover the penod of time back to the first day of your COBRA contmuation
coverage )
9 04 05 Duration COBRA Continuation Coverage can be extended for
a) 18 months if coverage ended due to a reduction m your work hours or
termmation of your employment and you or one of your covered Dependent(s) is
not Social Secunty disabled within 60 days of the date you lose coverage due to
termmation of employment or reduction m hours, the Medicare entitled person
may elect up to 18 months of COBRA If you are that Medicare entitled person,
your Dependents may elect COBRA for the longer of 36 months from your pnor
Medicare entitlement date, or 18 months from the date of your termination or
reduction in hours
b) 36 months for your Dependents, if your Dependents lose ehgibihty for medical
coverage due to your death, your divorce or legal separation, your entitlement to
Medicare after your termination or reduction m hours, or your Dependent child
ceasing to qualify as a Dependent under the plan
c) 29 months if you lose coverage due to a termmation of employment or reduction
m hours and you or a Dependent is disabled, as defined by Title II or Title XVI
of the Social Secunty Act, withm 60 days of the ongmal qualifying event In
this case, you may contmue coverage for an additional 11 months after the
original 18 -month period either for the disabled person only or for one or all of
your covered family members
To be eligible for extended coverage due to Social Secunty disability, you must notify the plan
administrator of the disability before the end of the initial 18 months of COBRA contmuation
coverage and within 60 days followmg the date you or a covered Dependent is determined to be
disabled by the Social Security Administration If the disabled mdividual should no longer be
considered to be disabled by the Social Security Administration, you must notify the plan
administrator within 30 days followmg the end of the disability Coverage that has exceeded the
onginal 18 -month contmuation period will end when the mdividual is no longer Social Security
disabled
If more than one qualifying event occurs, no more than 36 months total of COBRA contmuation
coverage will be available The COBRA beneficiary must experience the second qualifymg event
durmg the first 18 months of COBRA contmuation, and must provide notice to the plan
21
AV -G100 2004
Administrator withm the required time period COBRA continuation coverage will end sooner if
the plan terminates and the employer does not provide replacement medical coverage, or if a
person covered under COBRA
a) first becomes covered under another group health plan after the loss of coverage
due to your termination or reduction m hours, unless the new group coverage is
lumted due to a pre-existmg condition exclusion, this plan will be primary for the
pre-existmg condition and secondary for all other eligible health care expenses,
provided contributions for COBRA coverage contmue to be paid Coverage may
only contmue for the remainder of the ongmal COBRA period,
b) fails to make required contributions when due,
c) first becomes entitled to Medicare benefits after the moral COBRA qualifying
event, or
d) is extending the 18 -month coverage penod because of disability and is no longer
disabled as defined by the Social Security Act
9 05 Contmuation Coverage During Leaves of Absence
9 05 01 Family and Medical Leaves of Absence (FMLA) Under the Family and Medical
Leave Act of 1993, you may be entitled to up to a total of 12 weeks of unpaid, job -
protected leave during each calendar year for the followmg
a) the birth of your child, to care for your newborn child, or for placement of a child
in your home for adoption or foster care,
b) to care for your spouse, child or parent with a serious health condition, or
c) for your own senous health condition
If your FMLA leave is a paid leave, your pay will be reduced by your before -tax contributions as usual
for the coverage level m effect on the date your FMLA leave begms If your FMLA leave is unpaid, you
will be required to pay your contributions directly to the employer until you return to active pay status
If you notify your employer that you are termmating employment during your FMLA leave, your
coverage will end on the date of your notification If you do not return to work on your expected FMLA
return date, and you do not notify your employer of your mtent either to terminate your employment or to
extend the penod of leave, your Plan coverage will end on the date you were expected to return
You may not change your Plan elections during your FMLA leave unless an open enrollment occurs, or
unless you are on a paid FMLA leave and you have a change m status event or a special enrollment event
under HIPAA
9 05 02 Military Leaves of Absence If you are absent from work due to military service, you
may elect to continue coverage under the Plan (mcludmg coverage for enrolled
22
AV -6100 2004
Dependents) for up to 18 months from the first day of absence (or, if earlier, until the
day after the date you are required to apply for or return to active employment with
your employer under the Uniformed Services Employment and Reemployment
Rights Act of 1994 ("USERRA")) Your contributions for continued coverage will
be the same as for similarly situated active participants m the Plan
Whether or not you continue coverage during military service, you may remstate coverage under the Plan
option you elected on your return to employment under USERRA The reinstatement will be without any
waitmg penod otherwise required under the Plan, except to the extent that you had not fully completed
any required waitmg penod prior to the start of the military service
9 06 Conversion After Continuation Coverage See Section 804
9 07 Extension of Benefits In the event this Contract is terminated for any reason, except nonpayment
of premium or as set forth m 9 07 03, such termination shall be without prejudice to any
contmuous losses to a Subscnber or Member which commenced while this Contract was m force,
but any extension of benefits beyond the date of termination shall be predicated upon the
continuous Total Disability as defined m Section 3 44, of the Subscriber or Member and shall be
limited to payment for the treatment of a specific accident or illness incurred while the Subscnber
was a Member
9 07 01 The extension of benefits covered under this Contract shall be limited to the
occurrence of the earliest of the followmg events
a) The expiration of 12 months,
b) Such time as the Member is no longer totally disabled,
c) A succeeding carner elects to provide replacement coverage without Lmutation
as to the disability condition, or
d) The maximum benefits payable under this Contract have been paid
9 07 02 In the case of maternity coverage, when not covered by the succeeding career, a
reasonable extension of this Contract's benefits will be provided to cover maternity
expenses for a covered pregnancy that commenced while the pohcy was m effect
The extension shall be for the penod of that pregnancy only and shall not be based
upon Total Disability
9 07 03 Except as provided above, no Subscriber is entitled to an extension of benefits if the
termination by Health Plan of this Contract is based upon one or more of the
following reasons
a) Fraud or intentional misrepresentation m applying for any benefits under this
Contract
b) Disenrollment for cause
23
AV -G100 2004
c) The Subscnber has left the geographic Service Area of Health Plan with the
mtent to relocate or establish a new residence outside Health Plan's Service Area
X SCHEDULE OF BASIC BENEFITS
Health Plan is committed to arranging for comprehensive prepaid health care services rendered to its
Subscnbers through Health Plan's network of contracted independent Physicians and Hospitals and other
independent health care providers, under reasonable standards of quality health care The professional
judgment of a Physician licensed under Chapters 458 (physician), 459 (osteopath), 460 (chiropractor) or
461 (podiatrist), Flonda Statutes, concerning the proper course of treatment of a Subscnber shall not be
subject to modification by Health Plan or its Board of Directors, Officers, or Administrators However,
this subsection is not mtended to and shall not restrict any Utilization Management Program established
by Health Plan
Only services and benefits in conformity with Part III (Definitions), Part X (Schedule of Basic Benefits),
Part XI (Limitations of Basic Benefits), Part XII (Exclusions From Basic Benefits) and Schedule of Co -
payments, which by reference, is mcorporated herem, are covered by Health Plan 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 should remember that services that are provided or received without havmg been authonzed m
advance by AvMed Health Plan's Medical Department, or if the service is beyond the scope of practice
authonzed for that Provider under state law, except m instances of Emergency Services and Care, are not
covered unless such services otherwise have been expressly authonzed under the terms of this Contract
Except for Emergency Services and Care, all services must be received from Participatmg Providers on
referral from AvMed If a Member does not follow the access rules, he risks havmg services and supplies
received not covered under this Contract In such a circumstance, the Member will be responsible for
reimbursing AvMed for the reasonable cost of the services and supplies received
Also, Members must understand that services will not be covered if they are not, m AvMed Health Plan's
opinion, Medically Necessary Any and all decisions made by Health Plan m administering the
provisions of this Contract, mcludmg without limitation, the provisions of Part X (Schedule of Basic
Benefits), Part XI (Limitations of Basic Benefits), and Part XII (Exclusions from Basic Benefits), are
made only to determine whether payment for any benefits will be made by Health Plan Any and all
decisions that pertain to the medical need for, or desirability of the provision or non -provision of Medical
Services or benefits, including without hnutation, the most appropnate level of such Medical Services or
benefits, must be made solely by the Member and his Physician, in accordance with the normal
patient/physician relationship for purposes of determining what is in the best interest of the Member The
Health Plan does not have the right of control over the medical decisions made by the Member's
Physician or health care providers The ordering of a service by a Physician, whether Participatmg or
Non-Partictpatmg, does not in itself make such service Medically Necessary Subscnbmg Group and
Member acknowledge that it is possible that a Member and his Physician may determine that such
services or supplies are appropnate even though such services or supplies are not covered and will not be
paid for or arranged by AvMed Health Plan
24
AV -6100 2004
MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR CO -PAYMENTS WHICH
MUST BE PAID TO HEALTH CARE PROVIDERS FOR CERTAIN SERVICES, AT THE TIME
SERVICES ARE RENDERED, AS SET FORTH IN THE SCHEDULE OF CO -PAYMENTS
10 01 The names and addresses of Participating Providers and Hospitals are set forth in a separate
booklet which, by reference, is made a part hereof The hst of Participating Providers, which may
change from time to time, will be provided to all Subscnbmg Groups The list of Participating
Providers may also be accessed from the AvMed website at www AvMed org Notwithstanding
the pnnted booklet, the names and addresses of Participatmg Providers on file with Health Plan at
any given time shall constitute the official and controlling list of Participatmg Providers
10 02 Withm the Service Area, Members are entitled to receive the covered services and benefits only
as herein specified, appropriately prescribed or directed by Participating Physicians The covered
services and benefits listed in the Schedule of Basic Benefits are available only from Participatmg
Providers within the Service Area and, except for Emergency Services as provided m Section
10 12, Health Plan shall have no liability or obligation 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, mstitution or organization,
unless pnor arrangements have been made for the Member and confirmed by wntten referral or
authonzation from Health Plan
10 03 Each Member shall select one Pnmary Care Physician upon enrollment If you do not select a
Primary Care Physician upon enrollment, Health Plan will assign one for you You must notify
and receive approval by Health Plan prior to changmg your Primary Care Physician Such
change will become effective on the first day of the month after you notify Health Plan You
cannot change your PCP selection more than once per month The services of Specialty Health
Care Physicians are covered only when you are referred by your Pnmary Care Physician and as
approved by the Health Plan Health Professionals may from time to tune cease their affiliation
with Health Plan In such cases, you will be required to receive services from another
Participatmg Health Professional
1004 Any Member requirmg medical, Hospital, or ambulance services for Emergencies (as descnbed
m Sections 3 14 and 3 15), either while temporarily outside the Service Area or within the
Service Area but before they can reach a Participatmg Provider, may receive the Emergency
benefits as specified m Section 1012
10 05 Hospital Care Inpatient All Hospital mpatient services received at Participatmg Hospitals for
non -mental illness or mjury are provided when prescnbed by Participating Physicians and pre-
authonzed by Health Plan Inpatient Services mclude semi-pnvate room and board, birthing
rooms, newborn nursery care, nursmg care, meals and special diets when Medically Necessary,
use of operating room and related facilities, intensive care unit and services, diagnostic imaging,
laboratory and other diagnostic tests, drugs and medications, biologicals, anesthesia and oxygen
supplies, physical therapy, radiation therapy, respiratory therapy, and administration of blood or
blood plasma See Section 10 12 with regard to mpatient admission followmg Emergency
Services
25
AV -G100 2004
Health Plan pre -authorization is required for inpatient Hospital Services for substance abuse, and
these services are subject to the conditions set forth in the optional coverage selected (Also see
Section 11 05)
10 06 Physician Care Inpatient All Medical Services rendered by Participating Physicians and other
Health Professionals when requested or directed by the Attending Physician, mcluding surgical
procedures, anesthesia, consultation and treatment by Specialists, laboratory and diagnostic
imaging services, and physical therapy (See Section 10 08) are provided while the Member is
admitted to a Participatmg Hospital as a registered bed patient When available and requested by
the Member, Health Plan covers the services of a certified nurse anesthetist licensed under
Chapter 464, Flonda Statutes
10 07 Physician Care Outpatient
10 07 01 Diagnosis and Treatment All Medical Services rendered by Participatmg Physicians
and other Health Professionals, as requested or directed by the PCP, are covered
when provided at Medical Offices, including surgical procedures, routine hearing
examinations and vision examinations for glasses for children under age 18 (such
examinations may be provided by optometrists licensed pursuant to Chapter 463, FS
or by ophthalmologists licensed pursuant to Chapter 458 or 459, FS) and consultation
and treatment by Specialty Health Care Physicians Also mcluded are non -reusable
matenals and surgical supplies These services and matenals are subject to the
Limitations outlined in Part XI (Limitations of Basic Benefits) See Part XII for
Exclusions
10 07 02 Preventive and Health Mamtenance Services The services of the Member's Pnmary
Care Physician for illness prevention and health mamtenance, mcludmg Child Health
supervision services, and immun17 tions provided m accordance with prevailmg
medical standards consistent with the Recommendations for Preventive Pediatnc
Health Care of the Amencan Academy of Pediatncs and/or the Advisory Committee
on Immunization Practices, stenlization (See Schedule of Co -payments), periodic
health assessment, physical examinations, and voluntary family planning services are
also covered These services are subject to Limitations as outlined m Part XI
(Limitations of Basic Benefits) See Part XII for Exclusions
10 07 03 Outpatient Mental Health Services are covered only for diagnostic evaluation and
cnsis mtervention 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 Member's Participatmg Physician, and each visit requires a Co -
payment (See Schedule of Co -payments)
10 08 Physical, Occupational or Speech Therapy Short-term Physical, Occupational or Speech Therapy
provided m the Outpatient or Home Care setting is covered for acute conditions, including
exacerbation of previously treated conditions, for which therapy applied for a consecutive two (2)
month period can be expected to result m sigmficant improvement Coverage of outpatient
short-term and rehabilitative services is limited to twenty-four (24) visits per calendar year for all
26
AV -G100 2004
services combmed Long-term physical therapy, occupational therapy, speech therapy,
rehabilitation, or other treatment is not covered
10 09 Cardiac Rehabilitation Cardiac rehabilitation is covered for the followmg conditions acute
myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery
bypass graft (CABG), repair or replacement of heart valve(s) or heart transplant Coverage is
limited to a maximum of eighteen (18) visits per calendar year See Schedule of Co -payments for
detailed information regarding Co -payments and Limitations
10 10 Obstetrical and Gynecological Care Obstetncal care benefits as specified herem are covered and
mclude Hospital care, anesthesia, diagnostic imaging, and laboratory services for conditions
related to pregnancy unless such pregnancy is the result of a preplanned adoption arrangement,
more commonly known as surrogacy The length of maternity stay m a Hospital will be that
determined to be Medically Necessary in compliance with Flonda law and in accordance with the
Newborns' and Mothers' Health Protection Act, as follows 1) hospital stays of at least 48 hours
followmg a normal vaginal delivery, or at least 96 hours followmg a cesarean section, 2) the
attending physician does not need to obtain authorization from the Plan to prescribe a Hospital
stay of this length or longer, and 3) shorter Hospital stays are permitted if the attending health
care provider, m consultation with the mother, determines that this is the best course of action
Coverage for maternity care is subject to applicable Co -payments and all other Plan limits and
requirements Newborn child care is covered as provided m Subsection 4 02 02 (i) and Section
10 11 An annual gynecological examination and Medically Necessary follow-up care detected at
that visit are available without the need for a pnor referral from the Pnmary Care Physician
10 11 Newborn Care All services applicable for children under this Contract are covered for an
enrolled newborn child of the Subscriber or the enrolled newborn child of a covered Dependent
of the Subscnber or the newborn adopted child of the Subscnber (as descnbed m Subsection
4 02 02 (i)), from the moment of birth, mcludmg the Medically Necessary care or treatment of
medically diagnosed congenital defects, birth abnormalities or prematurity, and transportation
costs to the nearest facility appropnately staffed and equipped to treat the newborn's condition,
when such transportation is Medically Necessary Circumcisions are provided for up to one year
from date of birth provided that newborn was contmuously covered by Health Plan from date of
birth
10 12 Emergency Services All necessary Physician and Hospital Services will be covered by Health
Plan for Emergency Care (See Part III, Sections 3 14 and 3 15) In the event that Hospital
mpatient services are provided followmg Emergency Services, Health Plan should be notified
within 24 hours or as soon as the Member is lucid and able to notify Health Plan of the mpatient
admission Health Plan will pay the usual, reasonable, and customary charges to a non-
Participatmg Physician or facility only for those services rendered before a Member's condition
permits him to be reasonably able to travel to a Participating facility In addition, any Member
requests for reimbursement (of payment made by the Member for services rendered) must be filed
within ninety (90) days after the Emergency or as soon as reasonably possible but not later than
one (1) year unless the claimant was legally incapacitated
10 13 Urgent Care Services All necessary and covered services received m Urgent Care or Immediate
Care Centers or rendered in your Primary Care Physician's office after-hours for conditions as
27
AV -6100 2004
described m Section 3 46 will be covered by Health Plan See Schedule of Co -payments for
details In addition, any Member requests for reimbursement (of payment made by the Member
for services rendered) must be filed within ninety (90) days after the Emergency or as soon as
reasonably possible but not later than one (1) year unless the claimant was legally mcapacitated
10 14 Ambulance Service For an Emergency or when pre -authorized by Health Plan, ambulance
service to the nearest Hospital appropriately staffed and equipped to treat the condition will be
covered
10 15 Other Health Care Facility(ies) All routme services of Other Health Care Facilities (see Section
3 33), mcluding Physician visits, physiotherapy, diagnostic imaging and laboratory work, are
covered for a maximum of twenty (20) days per Calendar 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
1016 Diagnostic Imaging and Laboratory All prescnbed diagnostic imaging and laboratory tests and
services mcludmg diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and
other laboratory tests, and diagnostic clinical isotope services are covered when Medically
Necessary and ordered by a Participating Physician as part of the diagnosis and/or treatment of a
covered illness or mjury or as preventive health care services
10 17 Home Health Care Services With prior authonzation by Health Plan, Home Health Care
Services (as defined m Section 3 21) are covered when ordered by and under the direction of the
Member's Attending Physician Physical, Occupational or Speech Therapy services provided m
the home are limited as noted m 10 08 Homemaker or other Custodial Care services are not
covered
10 18 Hospice Services With pnor authonzation by Health Plan, services are available from a Health
Plan affiliated Hospice organization for a Member whose Participatmg Physician has determined
the Member's illness will result m a remaining life span of six (6) months or less
10 19 Second Medical Opmions The Member is entitled to a second medical opinion when he 1)
disputes the appropnateness or necessity of a surgical procedure, or 2) is subject to a senous
mjury or illness
With pnor notice to Health Plan, the Member may obtain the second medical opinion from any
Participatmg or non-Participatmg Physician, chosen by the Member, who is within Health Plan's
Service Area If a Participatmg Physician is chosen, there is no cost to the Member other than
any applicable Co -payment If the Member chooses a non -Participating Physician, the Member
will be responsible for 40% of the amount of reasonable and customary charges for the second
medical opimon
Any tests that may be required to render the second medical opinion must be arranged by Health
Plan and performed by Participating Providers Once a second medical opinion has been
rendered, Health Plan shall review and determine Health Plan's obligations under the contract and
that judgment is controllmg Any treatment the Member obtams that is not authorized by Health
Plan shall be at the Member's expense
28
AV -G100 2004
Health Plan may limit second medical opinions in connection with a particular diagnosis or
treatment to three (3) per Contract Year, if Health Plan deems additional opinions to be an
unreasonable over -utilization by the Member
10 20 Durable Medical Equipment and Orthotic Appliances
10 20 01 Durable Medical Equipment This Contract provides benefits, when Medically
Necessary, for the purchase or rental of such DME that
a) Can withstand repeated use (i e could normally be rented and used by successive
patients),
b) Is pnmanly and customanly used to serve a medical purpose,
c) Generally is not useful to a person m the absence of illness or mjury, and
d) Is appropriate for use m a patient's home
Some examples of DME are hospital beds, crutches, canes, walkers, wheelchairs,
respiratory equipment, apnea monitors and msulm pumps In accordance with
Flonda Statutes, coverage of msulm pumps for the treatment of diabetes will not
apply toward or be subject to the annual DME maximum Linutation It does not
mclude hearing aids or corrective lenses, mcludmg the professional fee for fitting
same It also does not mclude medical supplies and devices, such as a corset, which
do not require prescriptions AvMed will pay for rental of equipment up to the
purchase pnce Repair and/or replacement is not covered See Schedule of Co -
payments for any Co -payments or Limitations See Part XII for Exclusions
10 20 02 Orthotic Apphances Coverage for orthotic appliances is limited to custom-made leg,
arm, back and neck braces when related to a surgical procedure or when used m an
attempt to avoid surgery and when necessary to carry out normal activities of daily
livmg, excluding sports activities Coverage is limited to the first such item, repair
and/or replacement is not covered All other orthotic apphances are not covered See
Schedule of Co -payments for any Co -payments or Limitations See Part XII for
Exclusions
10 21 Prosthetic Devices This Contract provides benefits, when Medically Necessary, for prosthetic
devices Coverage for prosthetic devices is limited to artificial limbs, artificial joints, and ocular
prostheses Coverage includes the initial purchase, fittmg, or adjustment Replacement is
covered only when Medically Necessary due to a change in bodily configuration The mitial
prosthetic device followmg a covered mastectomy is also covered Replacement of mtraocular
lenses is covered only if there is a change in prescription which cannot be accommodated by
eyeglasses All other prosthetic devices are not covered See Schedule of Co -payments for any
Co -payments or Limitations See Part XII for Exclusions
29
AV -G100 2004
10 22 Payment to Non-Participatmg Providers When, m the professional judgment of Health Plan's
Medical Director, a Member needs covered medical or Hospital Services which require skills or
facilities not available from Participating Providers and it is m the best interest of the Member to
obtain the needed care from a Non-Participatmg Provider, upon authorization by the Medical
Director, payment not to exceed usual, customary and reasonable charges for such covered
services rendered by a Non-Participatmg Provider will be made by Health Plan Charges for
Non -Participating Hospital Services will be reimbursed m accordance with the covered benefits
the Member would be entitled to receive m a Participatmg Hospital
10 23 Prescription Drug Benefits Allergy serums and chemotherapy for cancer patients are covered
Coverage for msulm and other diabetic supplies is descnbed m Section 10 26, below Other
prescnption drugs are a covered benefit only when the Subscnbmg Group Contract mcludes a
supplemental Prescription Drug Rider
10 24 Ventilator Dependent Care With prior authorization by Health Plan, Ventilator Dependent Care
(See Section 3 48) is covered up to a total of 100 days lifetime maximum benefit
10 25 Major Organ Transplants at a facility deemed appropnate and authorized by Health Plan, as well
as associated immunosuppressant drugs are covered except those deemed expenmental (See
Section 12 15)
10 26 Diabetes Treatment for all Medically Necessary equipment, supphes, and services to treat
diabetes This mcludes outpatient self -management trammg and educational services, if the
Member's Primary Care Physician, or the Physician to whom the Member has been referred who
specializes in diabetes treatment, certifies the equipment, supphes, or services are Medically
Necessary Insulin pumps are covered under Section 10 20 Diabetes outpatient self -
management trammg and educational services must be provided under the direct supervision of a
certified diabetes educator or a board certified endocrinologist under contract with Health Plan
Insulin, msulm syringes, lancets, and test strips are covered under the Subscnbmg Group's
supplemental Prescnption Drug Rider In the event that a Subscnbmg Group does not purchase a
supplemental Prescnption Drug Rider, msulm, insulin syringes, lancets, and test strips are
covered subject to a $25 Member Co -payment per item for a 30 -day supply
10 27 Mammograms are covered m accordance with Florida Statutes one baseline mammogram is
covered for female Members between the ages of 35 and 39, a mammogram is available every
two years for female Members between the ages of 40 and 49, and a mammogram is available
every year for female Members aged 50 and older
In addition, one or more mammograms a year are available when based upon a Physician's
recommendation for any woman who is at risk for breast cancer because of a personal or family
history of breast cancer, because of having a history of biopsy -proven benign breast disease,
because of havmg a mother, sister, or daughter who has had breast cancer, or because a woman
has not given birth before the age of 30
30
AV -G100 2004
10 28 Osteoporosis Diagnosis and Treatment when Medically Necessary for high -risk mdividuals, e g
estrogen -deficient mdividuals, mdividuals with vertebral abnormalities, mdividuals on long-term
glucocorticoid (steroid) therapy, mdividuals with primary hyperparathyroidism, and mdividuals
with a family history of osteoporosis
10 29 Dermatological Services Health Plan will cover up to five (5) office visits per calendar year to a
Plan Dermatologist for Medically Necessary covered services subject to Sections 3 28 and 3 47
No pnor referral is required for these services
10 30 Mastectomy Surgery when performed for breast cancer Coverage for Post -Mastectomy
Reconstructive Surgery shall include 1) reconstruction of the breast on which the mastectomy
has been performed, 2) surgery and reconstruction on the other breast to produce a symmetncal
appearance, and 3) prostheses and physical complications during all stages of mastectomy
mcludmg lymphedemas The length of stay will not be less than that determined by the treatmg
Physician to be Medically Necessary in accordance with prevailmg medical standards and after
consultation with the covered patient Coverage is subject to any applicable Co -payments and
will require pre-authonzation of services as applicable to other surgical procedures or
hospitahzations under the Plan
10 31 General anesthesia and hospitalization services to a Member who is under 8 years of age and is
determined by a licensed dentist and the Member's Physician to require necessary dental
treatment m a Hospital or ambulatory surgical center due to a significantly complex dental
condition or a developmental disability m which patient management m the dental office has
proved to be ineffective, or if the Member has one or more medical conditions that would create
significant or undue medical nsk for the Member m the course of delivery of any necessary
dental treatment or surgery if not rendered m a Hospital or ambulatory surgical center Pre -
authorization by Health Plan is required There is no coverage for diagnosis or treatment of
dental disease
10 32 Coverage for cleft hp and cleft palate for Members under 18 years of age The coverage provided
by this section is subject to the terms and conditions applicable to other benefits
XI LIMITATIONS OF BASIC BENEFITS
The nghts of Members and obligations of Participatmg Providers hereunder are subject to the followmg
Limitations
11 01 In the event of any major disaster, Participatmg Providers shall render Hospital and Medical
Services provided under this Contract insofar as practical, according to their best judgment,
within the Limitations of such facilities and personnel as are then available, but Health Plan and
Participatmg 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
31
AV -G100 2004
11 02 In the event of circumstances not reasonably withm the control of Health Plan, such as complete
or partial destruction of facilities, act of God, war, not, civil insurrection, disabihty of a
significant part of Hospital or participating medical personnel or similar causes, if the rendition of
medical and Hospital Services provided under this Contract is delayed or rendered impractical,
neither Health Plan, Participatmg Providers nor any Physician shall have any habilrty or
obligation on account of such delay or 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 Periodic physical examinations are limited to those which m the judgment of the Member's
Primary Care Physician are essential to the mamtenance of the Member's good health
11 04 A Member shall select one Primary Care Physician upon enrollment If the Member does not
select a Primary Care Physician upon enrollment, a Primary Care Physician will be assigned by
Health Plan for the Member The Member may obtain assistance m making a selection by
contacting Health Plan
1105 Substance Abuse - Hospital Limitation 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 Inpatient alcohol or drug rehabihtation services are not covered
11 06 Visits to Licensed Dietitians/Nutntionists for treatment of diabetes, renal disease or obesity
control shall be limited to three (3) outpatient visits per calendar year, and each visit requires a
Co -payment (See Schedule of Co -payments and also Section 12 21)
11 07 Spmal manipulations will be covered only when Medically Necessary and prescribed by a
Participatmg Physician or by self -referral to a Participatmg Physician
11 08 The total benefit for Ventilator Dependent Care is hmited to 100 calendar days hfetune
maximum
11 09 Inpatient Hospital care for a medical "Emergency," m -area or out -of -area, will only be covered
when authonzed by Health Plan, after the Member or the Hospital notifies Health Plan withm 24
hours of admission or as soon as the Member is lucid and able to notify Health Plan of the
admission followmg Emergency Care and services
11 10 Other Health Care Facihty (ies) All routme mpatient services of Other Health Care Facilities
(See Section 3 33), including Physician visits, physiotherapy, diagnostic imaging and laboratory
work, are covered for a maximum of twenty (20) days per Calendar 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
11 11 Physical, Occupational or Speech Therapy Physical, Occupational or Speech therapies shall be
limited as explamed m Section(s) 10 08 and 10 17
11 12 Surgical or non -surgical procedures which are undertaken to improve or otherwise modify the
Member's external appearance shall be limited to reconstructive surgery to correct and repair a
32
AV -G100 2004
functional disorder as a result of a disease, mjury, or congenital defect or initial implanted
prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast
11 13 Hyperbanc Oxygen Treatments are 'muted to forty (40) treatments per condition as appropnate
pursuant to the Centers for Medicare and Medicaid Services (CMS) guidelines subject to
applicable Co -payments as hsted for Physical, Speech and Occupational Therapies
XII EXCLUSIONS FROM BASIC BENEFITS
Medical Services and benefits for the followmg classifications and conditions are not covered and are
excluded from the Schedule of Basic Benefits provided under this Contract
12 01 Treatment of a condition resulting from
a) Participation m a not or rebellion,
b) Engagement m an illegal occupation,
c) Commission of or attempted commission of an assault, commission or attempted commission
of a crime punishable as a felony,
12 02 Cosmetic, surgical or non -surgical procedures which are undertaken pnmanly to improve or
otherwise modify the Member's external appearance Also excluded are surgical excision or
reformation of any saggmg skm of any part of the body, mcludmg, but not lunited to the eyelids,
face, neck, abdomen, arms, legs, or buttocks, any services performed m connection with the
enlargement, reduction, implantation or change m appearance of a portion of the body, mcludmg,
but not limited to the face, lips, jaw, chm, nose, ears, breasts, or gemtals (mcludmg circumcision,
except newborns for up to one year from date of birth, see also Section 10 11), hair
transplantation, chemical face peels or abrasion of the skm, electrolysis depilation, removal of
tattoomg, or any other surgical or non -surgical procedures which are pnmanly for cosmetic
purposes or to create body symmetry Additionally, all medical comphcations as a result of
cosmetic, surgical or non -surgical procedures are excluded
12 03 Medical care or surgery not authonzed by a Participatmg Provider, except for Emergency
Services, or not withm the benefits covered by Health Plan
12 04 Dental Care, as defined m 3 11, for any condition except
12 04 01 When such services are for the treatment of trauma related fractures of the jaw or
facial bones or for the treatment of tumors,
12 04 02 Reconstructive jaw surgery for the treatment of deformities that are present and
apparent at birth, provided the Member was contmuously covered by Health Plan
from date of birth to date of surgery, or
33
AV -6100 2004
1204 03 Full mouth extraction when required before radiation therapy
12 05 Services related to the diagnosis/treatment of temporomandibular joint (TMJ) dysfunction except
when Medically Necessary, all dental treatment for TMJ
12 06 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions
caused by congenital or developmental deformity, disease, or mjury
12 07 Medical supplies mcluding, but not limited to ostomy supplies, urmary catheter bags, pre-
fabncated splints, Thromboemboletic/Support hose and all bandages
12 08 Home monitonng devices and measuring devices (other than apnea monitors), and any other
equipment or devices for use outside the Hospital
12 09 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
mtraocular lenses, artificial Joints and orthopedic hardware, and vascular grafts Dental
appliances, other corrective lenses and hearing aids, including the professional fee for fitting them
are not covered
12 10 Over-the-counter medications, all contraceptives (mcludmg drugs and devices), hypodermic
needles and syringes and self-adrmnistered injectable drugs except chemotherapy for cancer
patients, insulin and msulm syringes, and allergy serums
12 11 Travel expenses including expenses for ambulance services to and from a Physician or Hospital
except in accordance with Section 10 12
12 12 Treatment for chronic alcoholism and chronic drug addiction, except those services offered as a
basic health service (See Section 11 05)
12 13 Treatment for armed forces service -connected medical care (for both sickness and injury)
12 14 Custodial Care (as defined m Part III, Section 3 10)
12 15 Expenmental and/or investigational procedures unless approved per Florida Administrative Code,
Section 59B-12 001 For the purposes of this Contract, a drug, treatment, device, surgery or
procedure may be determined to be experimental and/or investigational if any of the following
applies
a) the Food and Drug Administration (FDA) has not granted the approval for general use, or
b) there are msufficient outcomes data available from controlled clinical trials published m peer -
reviewed literature to substantiate its safety and effectiveness for the disease or injury
involved, or
c) there is no consensus among practicmg physicians that the drug, treatment, therapy,
procedure or device is safe or effective for the treatment m question or such drug, treatment,
therapy, procedure or device is not the standard treatment, therapy, procedure or device
34
AV -G100 2004
utilized by practicing physicians m treatmg other patients with the same or similar condition,
or
d) such drug, treatment, procedure or device is the subject of an ongoing Phase I or Phase II
clmmcal mvestigation, or experimental or research arm of a Phase III cluucal mvestigation, or
under study to determine maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy
as compared with the standard means for treatment or diagnosis of the condition m question
12 16 Personal comfort items not Medically Necessary for proper medical care as part of the therapeutic
plan to treat or arrest the progression of an illness or mjury This Exclusion mcludes, but is not
lmuted to wigs (mcludmg partial hair pieces, weaves, and toupees), personal care kits, guest
meals and accommodations, maid service, television/radio, telephone charges, photographs,
complimentary meals, birth announcements, take home supplies, travel expenses other than
Medically Necessary ambulance services that are provided for m the covered benefits section, air
conditioners, humidifiers, dehumidifiers, and air purifiers or filters
12 17 Physical examinations or tests, such as premarital blood tests or tests for contmumg employment,
education, hcensmg, or msurance or that are otherwise required by a third party
12 18 Eye care mcludmg
a) Eye examinations for Plan Members 18 years of age or older for the purpose of determlmng
the need for sight correction (such as eye glasses or contact lenses),
b) Trammg or orthoptics, mcludmg eye exercises, or
c) Radial Keratotomy, refractory keratoplasty, Lasik surgery or any other corneal surgical
procedure to correct refractive error
12 19 Hearmg examinations for Plan Members 18 years of age or older for the purpose of determinmg
the need for hearmg correction
12 20 Cosmetics, dietary supplements, nutritional formulae, health or beauty aids
12 21 Gastric staphng, gastric bypass, gastnc banding, gastric bubbles, and other procedures for the
treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests
Ongomg visits other than establishing a program of obesity control
12 22 Gender reassignment surgery as well as any service, supply, or medical care associated with
gender reassignment or gender identity disorders
12 23 All drugs, devices, and other forms of treatment related to a diagnosis of sexual dysfunction
12 24 Infertility diagnosis, treatment, and supphes, including mfertility testing, treatment of mfertihty,
diagnostic procedures and artificial msemination, to determine or correct the cause or reason for
infertility or inability to achieve conception This mcludes artificial msemmation, m -vitro
fertilization, ovum or embryo placement or transfer, gamete mtra-fallopian tube transfer, or
35
AV -6100 2004
cryogemc or other preservation techniques used in such or similar procedures Also excluded are
obstetrical benefits when such pregnancy is the subject of a Preplanned Adoption Arrangement or
Surrogacy as defined under Chapter 63, Flonda Statutes Drugs for the treatment of mfertilrty are
not covered
12 25 Reversal of stenhzation procedures
12 26 Immunt7ations and medications for the purpose of foreign travel or employment
12 27 Acupuncture, biofeedback, hypnotherapy, massage therapy, sleep therapy, sex therapy,
behavioral training, cogmtive therapy, and vocational rehabihtation
12 28 Foot supports are not covered These mclude orthopedic or specialty shoes, shoe build-ups, shoe
orthotics, shoe braces, and shoe supports Also excluded is routine foot care, mcludmg trimming
of corns, calluses, and nails
12 29 The Medical and Hospital Services for a donor or prospective donor who is a Health Plan
Member when the recipient of an organ transplant is not a Health Plan Member Coverage is
provided for costs associated with the bone marrow donor -patients to the same extent as the
msured recipient The reasonable costs of searching for the bone marrow donor is limited to
immediate family members and the National Bone Marrow Donor Program
12 30 Diagnostic testmg and treatment related to mental retardation or deficiency, learning disabilities,
behavioral problems, developmental delays, Autism Spectrum Disorder or Attention Deficit
Disorder Expenses for remedial or special education, counseling, or therapy mcludmg
evaluation and treatment of the above -fisted conditions or behavioral taming whether or not
associated with manifest mental disorders or other disturbances
12 31 Emergency room services for non -emergency purposes (See Sections 3 14 and 3 15)
12 32 Hospital Services that are associated with excluded surgery or Dental Care
12 33 Any non -Plan treatment received by a Member, except m the case of an Emergency or when
specifically pre -authorized by Health Plan (See Sections 3 14 and 3 15)
12 34 Speech therapy for delayed or abnormal speech pathology is not covered
12 35 Alcohol or substance abuse rehabilitation, vocational rehabilitation, pulmonary rehabilitation,
long term rehabilitation, or any other rehabilitation program
12 36 Surgery for the reduction or augmentation of the size of the breasts except as required for the
comprehensive treatment of breast cancer
12 37 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 Subscnbmg Group Contract
36
AV -G100 2004
12 38 Hospital Exclusion If a Member elects to receive Hospital care from a non -Participating
attending Physician or a non-Participatmg Hospital, then coverage is excluded for the entire
episode of care, except when the admission was due to an Emergency or with pnor written
authorization of Health Plan
12 39 Ventilator Dependent Care, except as provided m Part X (Schedule of Basic Benefits) for 100
days lifetime maximum benefit
12 40 Pnvate duty nursing services
12 41 Any sickness or mjury for which the covered person is paid benefits, or may be paid benefits if
claimed, if the covered person is covered or required to be covered by Workers' Compensation
In addition, if the covered person enters mto a settlement giving up nghts to recover past or future
medical benefits under a Workers' Compensation law, Health Plan shall not cover past or future
Medical Services that are the subject of or related to that settlement Furthermore, if the covered
person is covered by a Worker's Compensation program that limits benefits if other than
specified health care providers are used and the covered person receives care or services from a
health care provider not specified by the program, this Health Plan shall not cover the balance of
any costs remaining after the program has paid
12 42 Complications of any non -covered service, mcluding the evaluation or treatment of any condition
which arses as a complication of a non -covered service
12 43 Any service or supply to eliminate or reduce dependency on or addiction to tobacco, including
but not limited to nicotine withdrawal programs, facilities, and supplies (e g transdermal
patches, Nicorette gum)
12 44 Services associated with autopsy or postmortem examinations, mcluding the autopsy
12 45 Exercise programs, gym memberships, or exercise equipment of any kind, including, but not
limited to exercise bicycles, treadmills, stairmasters, rowmg machines, free weights or resistance
equipment Also excluded are massage devices, portable whirlpool pumps, hot tubs, Jacuzzis,
sauna baths, swimming pools and similar equipment
12 46 Removal of warts, moles, skm tags, lipomas, keloids, scars, and other benign lesions is not
covered
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 other Group Health Insurance, HMO, Personal
Injury Protection and Medical Payments under the Automobile Insurance Laws of this or any
other jurisdiction, governmental organization, agency, or any other entity providing health or
accident benefits to a Member, mcluding but not limited to Medicare, Worker's Compensation,
Pubhc 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
37
AV -G100 2004
13 02 If any covered person is eligible for services or benefits under two or more plans as set forth m
Section 13 01, 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 combmed The
Member shall execute and deliver such mstruments and papers as may be required and do
whatever else is necessary to secure such nghts to Health Plan Failure to do so will result in
nonpayment of claims Requested information should be provided to Health Plan withm thirty
(30) days of request or Member will be responsible for payment of claun Information received
after one (1) year from date of service will not be considered
13 03 The standards governing the coordination of benefits are the followmg, pursuant to the provisions
of Section 627 4235, Flonda Statutes
13 03 01 The benefits of a pohcy 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
13 03 02 Except as stated m Subsection 13 03 03, 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, excludmg year of
birth, falls earlier m a year are determined before those of the policy or plan of
the parent whose birthday, excluding year of birth, falls later m that year, but
b) If both parents have the same birthday, the benefits of the pohcy or plan which
covered the parent for a longer penod 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 pohcy or plan which contains
provisions under which the benefits of a pohcy 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
13 03 03 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 havmg custody of the child
38
AV -6100 2004
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
provide the benefits of the pohcy or plan of that parent has actual knowledge of those
terms, the benefits of that pohcy or plan are determined first This does not apply
with respect to any claim determination penod or plan or pohcy year durmg which
any benefits are actually paid or provided before that entity has that actual
knowledge
13 03 04 The benefits of a policy or plan which covers a person as an employee who is neither
laid off nor retired, or as that employee's Dependent, are determined before those of a
policy or plan which covers that person as a laid off or retired employee or as that
employee's 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 Subsection
shall not apply
13 03 05 If none of the rules in Subsections 13 03 01, 13 03 02, 13 03 03, or 13 03 04
determine the order of benefits, the benefits of the pohcy or plan which covered an
employee, Member, or Subscriber for a longer penod of time are determined before
those of the pohcy or plan which covered that person for the shorter penod of time
13 03 06 Coordination of benefits shall not be permitted against an indemnity -type policy, an
excess insurance pohcy as defined m Section 627 635, Flonda Statutes, a policy with
coverage limited to specified illnesses or accidents, or a Medicare supplement pohcy
However, if the person is also a Medicare beneficiary, and if the rule established
under the Social Secunty Act of 1965, as amended, makes Medicare secondary to the
plan covermg the person as a Dependent of an active employee, the order of benefit
detenmmation is
a) First, benefits of a plan covermg a person as an employee, Member, or
Subscnber
b) Second, benefits of a plan of an active worker covermg a person as a Dependent
d) Third, Medicare benefits
13 03 07 If an individual is covered under a COBRA contmuation plan as a result of the
purchase of coverage as provided under the Consolidation Omnibus Budget
Reconciliation Act of 1987 (Pub L No 99-272), and also under another group plan,
the following order of benefits applies
a) First, the plan covering the person as an employee, or as the employee's
Dependent
39
AV -G100 2004
b) Second, the coverage purchased under the plan covering the person as a former
employee, or as the former employee's Dependent provided accordmg to the
provisions of COBRA
13 04 For the purpose of determ ing the applicability and implementing the terms of the Coordination
of Benefits provision of this agreement, Health Plan may, without the consent of or notice to any
person, release to or obtain from any other insurance company, organizations or person, any
mformation, with respect to any Subscnber or applicant for subscnption, which Health Plan
deems to be necessary for such purposes
13 05 Whenever payments which should have been made under this plan m accordance with this
provision have been made under any other plans, Health Plan shall have the nght, exercisable
alone and in its sole discretion, to pay over to any organizations making such other payments any
amounts Health Plan shall determine to be warranted in order to satisfy the mtent of this
provision, and amounts so paid shall be deemed to be Benefits paid under this Plan
13 06 All treatments must be Medically Necessary and comply with all terms, conditions, Limitations,
and Exclusions of this Plan even if Health Plan is secondary to other coverage and the treatment
is covered under the other coverage
XIV REIMBURSEMENT
In the event that Health Plan provides medical benefits or payments to a Member who suffers mjury,
disease, or illness by virtue of a negligent act or omission by a third party, Health Plan is entitled to
reimbursement from the Subscnber in accordance with 768 76 (4), Flonda Statutes
Member may be asked to provide a wntten assignment to Health Plan of Member's nghts to all claims,
demands, and rights to recovery that Member may have against the third party Health Plan may take any
action it deems necessary to protect its rights to recover the amount of any payments made by Health
Plan, mcluding the nght to bang suit m Member's name 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
Member shall hold such proceeds m trust for the benefit of Health Plan and pay them to Health Plan upon
demand if the proceeds have been paid directly to the Member
XV DISCLAIMER OF LIABILITY
15 01 Neither Subscnbmg 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 employees or of a Plan Hospital, or a Participating 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
40
AV -G100 2004
15 02 Neither Subscribers of Subscnbmg Group nor their Dependents shall be liable to Health Plan or
Participatmg Providers except as specifically set forth herem, provided all procedures set forth
herem are followed
15 03 Neither Health Plan nor its agents, servants or employees, nor any Member is the agent or
representative of the Subscnber 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 Subscnber Group
15 04 Health Plan does not directly employ any practicmg Physicians nor any Hospital personnel or
Physicians These health care providers are mdependent contractors and are not the agents or
employees of Health Plan Health Plan shall be deemed not to be a health care provider with
respect to any services performed or rendered by any such mdependent contractors Participatmg
providers mamtam the physician/patient relationslup with Members and are solely responsible for
all Medical Services which Participatmg Providers render to Members Therefore, Health Plan
shall not be liable for any neghgent act or omission committed by any independent practicmg
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 Health Plan Furthermore, Health Plan shall not be
vicariously hable for any neghgent act or omission of any of these mdependent health care
professionals who treat a Member(s) of Health Plan
15 05 Certam Members may, for personal reasons, refuse to accept procedures or treatment
recommended by Participatmg Physicians Participating Physicians may regard such refusal to
accept their recommendations as mcompatible with the continuance of the Physician/patient
relationship and as obstructmg the provision of proper medical care If a Member refuses to
accept the medical treatment or procedure recommended by the Participating Physician and if, m
the judgment of the Participatmg Physician, no professionally acceptable alternative exists or if
an alternative treatment does exist but is not recommended by the Participating Physician, the
Member shall be so advised
If the Member continues to refuse the recommended treatment or procedure, Health Plan may
terminate the Member's coverage under this Contract as set forth m Part IX, Subsection 9 01 05
XVI GRIEVANCE PROCEDURE
16 01 Urgent Care Claims
16 01 01 Initial Claim An Urgent Care Claim shall be deemed to be filed on the date received
by Health Plan AvMed shall notify the Claimant of the Health Plan's benefit
determmation (whether adverse or not) as soon as possible, taking mto account the
medical exigencies, but not later than 72 hours after the Health Plan receives, either
orally or in wntmg, the Urgent Care Claim, unless the Claimant fails to provide
sufficient information to determine whether, or to what extent, benefits are covered or
payable under the Health Plan If such information is not provided, AvMed shall
notify the Claimant as soon as possible, but not later than 24 hours after the Health
41
AV -6100 2004
Plan receives the Claim, of the specific information necessary to complete the Claim
The Claimant shall be afforded a reasonable amount of time, taking mto account the
circumstances, but not less than 48 hours, to provide the specified mformation
AvMed shall notify the Claimant of the Health Plan's benefit determination as soon as
possible, but in no case later than 48 hours after the earher of
1) The Health Plan's receipt of the specified information, or
2) The end of the penod afforded the Claimant to provide the specified additional
mformation
If the Claimant fails to supply the requested information within the 48 -hour penod, the Claim
shall be denied AvMed may notify the Claimant of its benefit determination orally or m wntmg
If the notification is provided orally, a written or electronic notification, meetmg the requirements
of Section 16 05 shall be provided to the Claimant no later than 3 days after the oral notification
16 01 02 Appeal A Claimant may appeal an Adverse Benefit Determination with respect to an
Urgent Care Claim within 180 days of receiving the Adverse Benefit Determination
AvMed shall notify the Claimant, m accordance with Section 16 07, of the Health
Plan's benefit determmation on review as soon as possible, taking into account the
medical exigencies, but not later than 72 hours after the Health Plan receives the
Claimant's request for review of an Adverse Benefit Determination
You may submit an appeal to
AvMed Member Services — North
P O Box 823
Gainesville, Flonda 32602-0823
Telephone 1-800-882-8633
Fax (352) 337-8612
AvMed Member Services — South
P 0 Box 569008
Miami, Florida 33256-9906
Telephone 1-800-882-8633
Fax (305) 671-4736
If you are not satisfied with AvMed's final decision, you may contact the Flonda Agency for
Health Care Administration (AHCA) or the Department of Financial Services (DFS) m
wntmg within 365 days of receipt of the final decision letter If you appeal AvMed's
decision, your grievance will be reviewed by the Subscnber Assistance Program You also
have the right to contact the AHCA or DFS at any time to mform them of an unresolved
grievance
The Subscriber Assistance Program will not hear a grievance if the Member has not
completed the entire AvMed Grievance process nor if the Member has instituted an action
pending m the state or federal court
If you need further assistance, you may contact
Subscnber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
42
AV -6100 2004
2727 Mahan Drive, Mail Stop 26
Tallahassee, Flonda 32308
Telephone 1-888-419-3456 or 850-921-5458
The Florida Department of Financial Services
200 East Games Street
Tallahassee, Flonda 32399
Telephone 1 800-342-2762
16 02 Pre -Service Claims
16 02 01 Initial Claim — A Pre -Service Claim shall be deemed to be filed on the date received by
Health Plan AvMed shall notify the Claimant of the Health Plan's benefit
determination (whether adverse or not) within a reasonable penod of time appropnate
to the medical circumstances, but not later than 15 days after the Health Plan receives
the Pre -Service Claim The Health Plan may extend this penod one time for up to 15
days, provided that AvMed determines that such an extension is necessary due to
matters beyond the Health Plan's control and notifies the Claimant, before the
expiration of the initial 15 -day penod, of the circumstances requirmg the extension of
time and the date by which the Health Plan expects to render a decision If such an
extension is necessary because the Claimant failed to submit the mformation necessary
to decide the Claim, the notice of extension shall specifically descnbe the required
mformation, and the Claimant shall be afforded at least 45 days from receipt of the
notice withm which to provide the specified mformation In the case of a failure by a
Claimant to follow the Plan's procedures for filing a Pre -Service Claim, the Claimant
shall be notified of the failure and the proper procedures to be followed in filing a
Claim for benefits not later than five (5) days followmg such failure The Plan's penod
for making the benefit determination shall be tolled from the date on which the
notification of the extension is sent to the Claimant until the date on which the
Claimant responds to the request for additional information If the Claimant fails to
supply the requested mformation withm the 45 -day period, the Claim shall be denied
16 02 02 Appeal — A Claimant may appeal an Adverse Benefit Determination with respect to a
Pre -Service Claim within 180 days of receivmg the Adverse Benefit Determination
AvMed shall notify the Claimant, m accordance with Section 16 07, of the Health
Plan's determination on review withm a reasonable penod of time Such notification
shall be provided not later than 30 days after the Health Plan receives the Claimant's
request for review of the Adverse Benefit Determination
You may submit an appeal to
AvMed Member Services — North
P 0 Box 823
Gamesville, Flonda 32602-0823
Telephone 1-800-882-8633
Fax (352) 337-8612
43
AV -G100 2004
AvMed Member Services — South
P 0 Box 569008
Miami, Flonda 33256-9906
Telephone 1-800-882-8633
Fax (305) 671-4736
If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for
Health Care Administration (AHCA) or the Department of Financial Services (DFS) m
wntmg within 365 days of receipt of the final decision letter If you appeal AvMed's
decision, your grievance will be reviewed by the Subscnber Assistance Program You also
have the right to contact the AHCA or DFS at any tune to mform them of an unresolved
grievance
The Subscnber Assistance Program will not hear a grievance if the Member has not
completed the entire AvMed Gnevance process nor if the Member has instituted an action
pending in the state or federal court
If you need further assistance, you may contact
Subscnber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Dnve, Mail Stop 26
Tallahassee, Flonda 32308
Telephone 1-888-419-3456 or 850-921-5458
The Flonda Department of Financial Services
200 East Gaines Street
Tallahassee, Flonda 32399
Telephone 1-800-342-2762
16 03 Post -Service Claims
16 03 01 Initial Claim — A Post -Service Claim shall be deemed to be filed on the date received
by Health Plan AvMed shall notify the Claimant, m accordance with Section 16 05 of
the Health Plan's Adverse Benefit Determination withm a reasonable penod of time,
but not later than 30 days after the Health Plan receives the Post -Service Claim The
Health Plan may extend this penod one time for up to 15 days, provided that AvMed
determines that such an extension is necessary due to matters beyond the Health Plan's
control and notifies the Claimant, before the expiration of the initial 30 -day period, of
the circumstances requiring the extension of time and the date by which the Health Plan
expects to render a decision If such an extension is necessary because the Claimant
failed to submit the mformation necessary to decide the Post -Service Claim, the notice
of extension shall specifically descnbe the required information, and the Claimant shall
be afforded at least 45 days from receipt of the notice within which to provide the
specified mformation The Plan's penod for making the benefit determination shall be
tolled from the date on which the notification of the extension is sent to the Claimant
until the date on which the Claimant responds to the request for additional information
If the Claimant fails to supply the requested mformation within the 45 -day penod, the
Claim shall be denied
16 03 02 Appeal — A Claimant may appeal an Adverse Benefit Determination with respect to a
Post -Service Claim within 180 days of receivmg the adverse Benefit Determunation
44
AV -G100 2004
AvMed shall notify the Claimant, in accordance with Section 16 07, of the Health
Plan's determination on review within a reasonable period of time Such notification
shall be provided not later than 60 days after the Health Plan receives the Claimant's
request for review of the Adverse Benefit Determination
You may submit an appeal to
AvMed Member Services — North
P O Box 823
Gainesville, Flonda 32602-0823
Telephone 1-800-882-8633
Fax (352) 337-8612
AvMed Member Services — South
P O Box 569008
Miami, Flonda 33256-9906
Telephone 1-800-882-8633
Fax (305) 671-4736
If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for
Health Care Administration (AHCA) or the Department of Financial Services (DFS) in
wntmg within 365 days of receipt of the final decision letter If you appeal AvMed's
decision, your gnevance will be reviewed by the Subscnber Assistance Program
You also have the right to contact the AHCA or DFS at any time to inform them of an
unresolved gnevance
The Statewide Provider and Subscnber Assistance Program will not hear a grievance if the
Member has not completed the entire AvMed Grievance process nor if the Member has
instituted an action pending m the state or federal court
If you need further assistance, you may contact
Subscnber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Dnve, Mail Stop 26
Tallahassee, Flonda 32308
Telephone 1-888-419-3456 or 850-921-5458
The Florida Department of Insurance
200 East Games Street
Tallahassee, Flonda 32399
Telephone 1-800-342-2762
16 04 Concurrent Care Claims
1604 01 Any reduction or termination by the Health Plan of Concurrent Care (other than by
plan amendment or termination) before the end of an approved penod of time or
number of treatments, shall constitute an Adverse Benefit Determination AvMed shall
notify the Claimant, m accordance with Section 16 05, of the Adverse Benefit
Determination at a time sufficiently m advance of the reduction or termination to allow
45
AV G100 2004
the Claimant to appeal and obtain a determination on review of the Adverse Benefit
Determination before the benefit is reduced or terrmnated
16 04 02 Any request by a Claimant to extend the course of treatment beyond the penod of time
or number of treatments that relates to an Urgent Care Clain shall be decided as soon
as possible, taking mto account the medical exigencies, and AvMed shall notify the
Claimant of the benefit determ nation, whether adverse or not, within 24 hours after the
Health Plan receives the Claim, provided that any such Claim is made to the Plan at
least 24 hours before the expiration of the prescnbed penod of time or number of
treatments Notification and appeal of any Adverse Benefit Determination concerning
a request to extend the course of treatment, whether mvolvmg an Urgent Care Claim or
not, shall be made m accordance with the remamder of Section XVI
16 05 Manner and Content of Initial Claims Determination Notification AvMed shall provide a Claimant
with written or electromc notification of any Adverse Benefit Determination The notification shall
set forth, in a manner calculated to be understood by the Claimant, the followmg
16 05 01 The specific reason(s) for the Adverse Benefit Determination
16 05 02 Reference to the specific Health Plan provisions on which the determination is based
16 05 03 A description of any additional matenal or information necessary for the Claimant to
perfect the Claim and an explanation of why such material or information is necessary
16 05 04 A description of the Health Plan's review procedures and the time limits applicable to
such procedures, mcludmg, when applicable a statement of the Claimant's nght to
brmg a civil action under section 502(a) of the Employee Retirement Income Security
Act of 1974, as amended (ERISA), followmg an Adverse Benefit Determination on
final review
16 05 05 If an mtemal rule, guideline, protocol, or other similar cntenon was relied upon m
making the Adverse Benefit Determination, either the specific rule, guideline, protocol,
or other similar cntenon or a statement that such rule, guideline, protocol or other
similar cntenon was rehed upon m making the Adverse Benefit Determination and that
a copy shall be provided free of charge to the Claimant upon request
16 05 06 If the Adverse Benefit Determination is based on whether the treatment or service is
Experimental and/or Investigational or not Medically Necessary, either an explanation
of the scientific or clinical judgment for the determination, applying the terms of the
Health Plan to the Claimant's medical circumstances, or a statement that such
explanation shall be provided free of charge upon request
16 05 07 In the case of an Adverse Benefit Determination mvolvmg an Urgent Care Claim, a
descnption of the expedited review process applicable to such Claim
46
AV -G100 2004
16 06 Review Procedure Upon Appeal The Health Plan's appeal procedures shall include the
following substantive procedures and safeguards
16 06 01 Claimant may submit wntten comments, documents, records, and other information
relatmg to the Claim
16 06 02 Upon request and free of charge, the Claimant shall have reasonable access to and
copies of any Relevant Document
16 06 03 The appeal shall take into account all comments, documents, records, and other
mformation the Claimant submitted relatmg to the Claim, without regard to whether
such information was submitted or considered in the initial Adverse Benefit
Determination
16 06 04 The appeal shall be conducted by an appropnate named fiduciary of the Health Plan
who is neither the mdividual who made the initial Adverse Benefit Determination nor
the subordinate of such mdividual Such person shall not defer to the initial Adverse
Benefit Determination
16 06 05 In deciding an appeal of any Adverse Benefit Determination that is based m whole or m
part on a medical judgment, including determinations with regard to whether a
particular treatment, drug, or other item is Expenmental and/or Investigational or not
Medically Necessary, the appropnate named fiduciary shall consult with a Health Care
Professional who has appropnate training and expenence in the field of medicine
involved m the medical judgment
16 06 06 The appeal shall provide for the identification of medical or vocational experts whose
advice was obtained on behalf of the Health Plan in connection with a Claimant's
Adverse Benefit Determination, without regard to whether the advice was rehed upon
m making the Adverse Benefit Determination
16 06 07 The appeal shall provide that the Health Care Professional engaged for purposes of a
consultation m Subsection 16 06 05 shall be an mdividual who is neither an mdividual
who was consulted m connection with the initial Adverse Benefit Determination that is
the subject of the appeal, nor the subordinate of any such individual
16 06 08 In the case of an Urgent Care Claim, there shall be an expedited review process
pursuant to which
a) a request for an expedited appeal of an Adverse Benefit Determination may be
submitted orally or m wntmg by the Claimant, and
b) all necessary mformation, including the Health Plan's benefit determination on
review, shall be transmitted between the Health Plan and the Claimant by
telephone, facsimile, or other available similarly expeditious methods
16 07 Manner and Content of Appeal Notification AvMed shall provide a Claimant with wntten or
electronic notification of the Health Plan's benefit determination upon review
47
AV -G100 2004
16 07 01 In the case of an Adverse Benefit Determination, the notification shall set forth, m a
manner calculated to be understood by the Claimant, all of the followmg, as
appropnate
a) The specific reason(s) for the Adverse Benefit Determination
b) Reference to the specific Health Plan provisions on which the Adverse Benefit
Determination is based
c) A statement that the Claimant is entitled to receive, upon request, and free of
charge, reasonable access to, and copies of any Relevant Document
d) A statement descnbmg any voluntary appeal procedures offered by the Health Plan
and the Claimant's nght to obtain the information about such procedures and a
statement of the Claimant's right to brmg an action under ERISA Section 502(a)
when applicable
e) If an mtemal rule, guideline, protocol, or other similar cntenon was relied upon m
making the Adverse Benefit Determination, either the specific rule, guidelme,
protocol, or other similar cntenon or a statement that such rule, guidelme, protocol,
or other similar cntenon was relied upon m making the Adverse Benefit
Determination and that a copy shall be provided free of charge to the Claimant
upon request
f) If the Adverse Benefit Determination is based on whether the treatment or service
is Expenmental and/or Investigational or not Medically Necessary, either an
explanation of the scientific or clinical judgment for the determination, applymg
the terms of the Health Plan to the Claimant's medical circumstances, or a
statement that such explanation shall be provided free of charge upon request
XVII MISCELLANEOUS
17 01 Contracting Parties By executmg this Contract, Subscnbmg Group and Health Plan agree to
make the medical and Hospital Services specified herem available to persons who are eligible
under the provisions of Part IV However, the delivery of benefits and services covered m this
Contract shall be subject to the provisions, Limitations, and Exclusions set forth herein and any
amendments, modifications, and Contract termination provisions specified herem and by the
mutual agreement between Health Plan and Subscnbmg Group, without the consent or
concurrence of the Members By electmg or acceptmg 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 vand unless approved by an executive officer
of Health Plan and endorsed herem or attached hereto No agent has authonty to change this
Contract or to waive any of its provisions
48
AV -G100 2004
17 02 Certificate of Coverage Health Plan shall provide a copy of the Certificate of Coverage for
each Subscnber
17 03 Membership Application 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 mdividual
Any person who knowmgly and with mtent to injure, defraud, or deceive any insurer files a
statement of Claim or an application containing any false, incomplete, or misleading information
is guilty of a felony, pumshable as provided by Flonda Statutes
1704 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 nght to
health services or other benefits under this Contract To be entitled to such services or benefits
the holder of the card must, m fact, be a Member on whose behalf all applicable charges under
this Contract have actually been paid and accepted by Health Plan
17 05 Waiver A Claim which has not been timely filed with Health Plan within one (1) year of date of
service, shall be considered waived
17 06 Non -Waiver The failure of Health Plan to enforce any of the provisions of this Contract or to
exercise any options herem provided or to require timely performance by any Member or
Subscnber 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 nght of Health
Plan to thereafter enforce each and every such provision
17 07 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
17 08 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
If to Health Plan, to
AvMed Health Plans
P 0 Box 749
Gamesville, Flonda 32602-0749
(OR if from a Member to Health Plan see the Member's Service Area address listed on Page i )
If to a Member To the last address provided by the Member and actually received by Health
Plan on the enrollment or change of address notification
If to Subscnbmg Group To the address provided m the Group Master Application
49
AV -G100 2004
17 09 Gender Whenever used, the singular shall include the plural and the plural the singular and the
use of any gender shall include all genders
17 10 Clerical Errors Clencal error(s) shall neither deprive any individual Member of 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 Retroactive
adjustments m coverage, for clerical errors or otherwise will only be done for up to a 60 day
penod from the date of notification Refunds of premiums are done for up to a 60 day penod
from the date of notification Refunds of premiums are limited to a total of 60 days from the date
of notification of the event, provided there are no Claims incurred subsequent to the effective date
of such event
17 11 Contract Review Subscnbmg 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
17 12 Premium Tax/Surcharge If any government entity shall impose a premium tax or surcharge,
then the sums due from the Subscnbmg Group under the terms of this Contract shall be increased
by the amount of such premium tax or surcharge
17 13 Entirety of Contract. This Agreement and all applicable Schedules, Exhibits, Riders and any
other attachments and endorsements, constitute the entire Contract between the Subscnbing
Group and Health Plan No modification (or oral representation) of this Group Contract shall be
of any force or effect unless it is in wntmg and signed by both parties
17 14 Rate Letter The "rate letter" is Health Plan's formal notice to the Subscnbmg 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, Health Plan's reservation of the right to adjust (re -rate) the premium quote to account
for changes m the group size or m the data supplied by the Subscnbmg 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
17 15 Third Party Beneficiary This Contract is entered into exclusively between the Subscribing
Group and Health Plan This Contract is intended only to benefit the Subscnbmg Group and the
Member(s) and does not confer any nghts on any other third parties
17 16 Assignment. This Contract, and all nghts and benefits related thereto, may not be assigned by
the Subscribing Group or the Member(s) without wntten consent of Health Plan
17 17 Applicability of Law The provisions of this Contract shall be deemed to have been modified by
the parties, and shall be interpreted, so as to comply with the laws and regulations of the State of
Florida and the Umted States
50
AV -G100 2004
17 18 ERISA When this Contract is purchased by the Subscnbmg Group to provide benefits under a
welfare plan governed by the Employee Retirement Income Secunty Act (ERISA), AvMed shall
be considered a fiduciary to the extent that it performs any discretionary functions on behalf of
the plan If a Member has questions about the group's welfare plan, the Member should contact
the Subscnbmg Group
51
AV -G100 2004
AvMn
HEALTH PLANS
Contract Number (s)
Subscribing Group Name
Effective Date
AVMED, INC d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application
004515
VILLAGE OF KEY BISCAYNE
May 1 2005
Group Contract
This Group Contract provides the benefits checked below
BASIC OPTION ($15 Specialist)
❑ $0 per Admission
❑ $100 per Admission
❑ $250 per Admission
❑ $250 per Day Days 1 5
BASIC OPTION ($25 Specialist)
❑ $0 per Admission
❑ $100 per Admission
❑ $250 per Admission
❑ $250 per Day Days 1 5
BASIC OPTION ($30 Specialist)
❑ $250 per Day Days 1 5
❑ $250 per Admission
Benefit Designs
BASIC OPTION ($35 Specialist)
❑ $250 per Day Days 1 5
❑ $250 per Admission
❑ $300 per Day Days 1 5
STANDARD OPTION ($10 Specialist)
❑ $0 per Admission
❑ $100 per Admission
❑ $100 per Day Days 1 5
12 $250 per Admission
STANDARD OPTION ($20 Specialist)
❑ $100 per Day Days 1 5
❑ $250 per Admission
OTHER LARGE GROUP BENEFITS
❑ $15/$250 PER Day Days 1 5
12 $25/$500 PER Day Days 1 5
❑ $20/$250/10%
❑ $20/$250/20%
❑ $25/$500/20%
❑ $25/$750/20%
❑ $30/$750/20%
CORE
❑ $15/$250/25-40%
11 $15/$500/15 30%
12 $25/$250/25-40%
❑ $15/$1000/10 25%
❑ $15/$100/30-40%
❑ $25/$100/30-40%
CDHP
O Consumer 1A
❑ Consumer - 1B
O Consumer 1C
Form AV STD/20-250A 04
If selected the following optional and supplemental coverage is also provided as described in the amendments to this contract
0
zi
❑
z
Open Access
Prescnption Coverage
Vision Coverage
Dental Coverage (ADP)
(All Dental Plans are administered by American Dental Plan)
Elective Termination of Pregnancy
Form AV
Form AV G100 RX 15/30/50 OC 03
Form AV VISION R 99
Form AV
Form AV G100 ETP R 97
Mental Health/Partial Hospitalization Form AV G100 MH/PH $250 per admit 04
❑ Group declines mental health benefits (Section 627 668 Florida Statutes)
Substance Abuse Form AV SA R 98
0 Group declines substance abuse benefits (Section 627 669 Flonda Statutes)
Durable Medical Equipment
Waiver of Co -payment — Coverage for Mammograms
Other
Q9 Injectable Drug Benefits
® Domestic Partner
Form AV G100 DME 2000 R 01
Form AV MAMMOGRAM R 02
Form AV AV G100 IDB $75 04
Form AV DP 12 R 02
AVMED, INC d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
ELIGIBILITY
An employee of the Subscnbing Group must be employed a minimum of 30 hours per week to become eligible for coverage
under this Contract
An employee becomes eligible for coverage under this Contract (Check and/or fill in as appropriate)
❑ on the date of hire
❑ consecutive days after the date of hire
® on the first day of the month following 30 consecutive days after the date of hire
❑ other
TERMINATION
Termination of coverage under this Contract shall become effective
® on the date the employee s employment is terminated
O on the last date of the month in which the employee s employment is terminated
O on the date the Group Contract is terminated
O other
AGREEMENT
This Contract is issued in consideration of the Master Application of the Subscnbing Group for group medical and hospital
services and the monthly prepayment subscnption charges and the mutual promises and benefits between AVMED Inc d/b/a
AVMED Health Plans and the Subscribing Group This Contract shall remain in effect for a penod of twelve (12) months from
the effective date of May 1 2005 and may be renewed annually not later than the anniversary date upon mutual agreement of
the parties The Contract period begins at 12 01 a m Eastern Standard Time on the effective date or on the anniversary date if
a renewal This Contract shall be govemed by Chapter 641 Florida Statutes and other applicable State and Federal laws
The first monthly payment is due on May 1 2005 Subsequent payments are due on the first day of each month thereafter
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE DEFRAUD OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION
IS GUILTY OF A FELONY OF THE THIRD DEGREE
AVMED, INC d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
MONTHLY CHARGES
Monthly Membership Charges
Subscnber Only $ 295 42
Subscriber plus Spouse $ 590 85
Subscriber plus One Dependent (No Spouse) $ 590 85
Subscriber plus Two or More Dependents $ 856 73
Subscriber plus Spouse and One or More Dependents $ 856 73
❑ Other $
The provisions contained in the Schedule of Co payments applicable to this Contract and all Exhibits and Amendments
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 is May 1 2005
Subscnbing Group
By
14e
Signature
7upLine. R �enendPL
Nam�e,
(�iL(-A&C / 143AfA e2
Title
Date 15/b *-r
AV G100 APP 04
MP 2027 (12/04)
AVMED Inc d /- .V ED Health Plans
By
Signature
Name
Date
Title
,/r o'
o
HEALTH PLANS
STANDARD OPTION/20
250 -ADMIT
Benefit Summary
SCHEDULE OF COPAYMENTS
COST TO MEMBER
OUT -OF POCKET MAXIMUM
$1 500 INDIVIDUAL
$3 000 FAMILY
AVMED PRIMARY CARE
PHYSICIAN
Services at participating doctors' offices include but are not
limited to
• ROUTINE OFFICE VISITS / ANNUAL GYN
EXAMINATION WHEN PERFORMED BY
PRIMARY CARE PHYSICIAN
• MATERNITY OUTPATIENT VISITS
• PEDIATRIC CARE & WELL BABY CARE
■ PERIODIC HEALTH EVALUATION &
IMMUNIZATIONS
• DIAGNOSTIC IMAGING LABORATORY OR
OTHER DIAGNOSTIC SERVICES
• MINOR SURGICAL PROCEDURES
• VISION & HEARING EXAMINATIONS FOR
CHILDREN UNDER 18
$10 PER VISIT
AVMED SPECIALIST'S
SERVICES
• OFFICE VISITS
■ ANNUAL GYN EXAMINATION WHEN
PERFORMED BY PARTICIPATING SPECIALIST
$20 PER VISIT
HOSPITAL
Inpatient care at participating hospitals includes
• ROOM & BOARD UNLIMITED DAYS (SEMI-
PRIVATE)
• PHYSICIAN S SPECIALIST S & SURGEON S
SERVICES
• ANESTHESIA USE OF OPERATING & RECOVERY
ROOMS OXYGEN DRUGS & MEDICATION
• INTENSIVE CARE UNIT & OTHER SPECIAL
UNITS GENERAL & SPECIAL DUTY NURSING
• LABORATORY & DIAGNOSTIC IMAGING
• REQUIRED SPECIAL DIETS
• RADIATION & INHALATION THERAPIES
$250 PER ADMISSION
100% COVERAGE
THEREAFTER
OUTPATIENT SURGERY
• OUTPATIENT SURGERIES INCLUDING CARDIAC
CATHETERIZATIONS AND ANGIOPLASTY
$250 COPAYMENT
OUTPATIENT DIAGNOSTIC
TESTS
EMERGENCY SERVICES
• CAT Scan PET Scan MRI
• OTHER DIAGNOSTIC IMAGING TESTS
An emergency is the sudden & unexpected onset of a condition
requiring immediate medical or surgical care (Copayment
waived if admitted )
• EMERGENCY SERVICES AT PARTICIPATING
HOSPITALS
• EMERGENCY SERVICES - NON PARTICIPATING
HOSPITALS, FACILITIES &/OR PHYSICIANS
AVMED MUST BE NOTIFIED WITHIN 24 HOURS OF
INPATIENT ADMISSION FOLLOWING EMERGENCY
SERVICES OR AS SOON AS REASONABLY POSSIBLE
$25 PER TEST
$10 PER TEST
$75 COPAYMENT
$100 COPAYMENT
URGENT/IMMEDIATE CARE
• MEDICAL SERVICES AT A PARTICIPATING
URGENT/IMMEDIATE CARE FACILITY OR
SERVICES RENDERED AFTER HOURS IN YOUR
PRIMARY CARE PHYSICIAN S OFFICE
• MEDICAL SERVICES AT A NON PARTICIPATING
URGENT/IMMEDIATE CARE FACILITY
$40 COPAYMENT
$60 COPAYMENT
Benefit Summary, continued
MENTAL HEALTH • 20 OUTPATIENT VISITS
$25 PER VISIT
FAMILY PLANNING • VOLUNTARY FAMILY PLANNING SERVICES
• STERILIZATION
$10 PER VISIT
$100 COPAYMENT
ALLERGY TREATMENTS • INJECTIONS
• SKIN TESTING
$10 PER VISIT
$50 PER COURSE OF
TESTING
AMBULANCE
• WHEN PRE AUTHORIZED OR IN THE CASE OF
EMERGENCY
• AIR TRANSPORT SERVICES
NO CHARGE
20% OF CONTRACTED RATE
(WHEN APPLICABLE) OR
20% OF BILLED CHARGES
UP TO $1 000
PHYSICAL, SPEECH, &
OCCUPATIONAL THERAPIES
• SHORT TERM PHYSICAL SPEECH OR
OCCUPATIONAL THERAPY FOR ACUTE
CONDITIONS
• COVERAGE IS LIMITED TO 24 VISITS PER
CALENDAR YEAR FOR ALL SERVICES
COMBINED
REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL
SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS &
LIMITATIONS
$10 PER VISIT
SKILLED NURSING
FACILITIES &
REHABILITATION CENTERS
• UP TO 20 DAYS POST HOSPITALIZATION CARE
PER CALENDAR YEAR WHEN PRESCRIBED BY
PHYSICIAN & AUTHORIZED BY AVMED
$25 PER DAY
CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following conditions
• ACUTE MYOCARDIAL INFARCTION
• PERCUTANEOUS TRANSLUMINAL CORONARY
ANGIOPLASTY (PTCA)
■ REPAIR OR REPLACEMENT OF HEART VALVE(S)
• CORONARY ARTERY BYPASS GRAFT (CABG) or
■ HEART TRANSPLANT
COVERAGE IS LIMITED TO 18 VISITS PER YEAR
$20 PER VISIT
BENEFITS LIMITED TO
$1 500 PER CONTRACT
YEAR
HOME HEALTH CARE • PER OCCURRENCE
NO CHARGE
DURABLE MEDICAL
EQUIPMENT & ORTHOTIC
APPLIANCES
Equipment includes
• HOSPITAL BEDS
• WALKERS
• CRUTCHES
• WHEELCHAIRS
Orthotic appliances are limited to
• LEG ARM BACK AND NECK CUSTOM MADE
BRACES
REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL
SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS &
LIMITATIONS
$50 PER EPISODE OF
ILLNESS BENEFITS
LIMITED TO $500 PER
CONTRACT YEAR
PROSTHETIC DEVICES Prosthetic devices are limited to
• ARTIFICIAL LIMBS
• ARTIFICIAL JOINTS
• OCULAR PROSTHESES
REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL
SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS &
LIMITATIONS
NO CHARGE
FOR ADDITIONAL INFORMATION, PLEASE CALL 1-800-88-AVMED (1-800-882-8633)
THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT
FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS & LIMITATIONS PLEASE SEE YOUR AVMED GROUP
MEDICAL & HOSPITAL SERVICE CONTRACT
AV STD/20 250A 04
MP 3413 (10/04)
Av
HEALTH PLANS
Prescription Drug Benefits
$15/30150 COPAYMENT with Contraceptives
DEFINITIONS
Brand drug means a Prescnption Drug which is usually manufactured and sold under a name or trademark by a drug manufacturer or a drug
which is identified as a Brand drug by AvMed AvMed delegates determination of Genenc/Brand status to our Pharmacy Benefits Manger
Brand Additional Charge means the additional charge which must be paid if you or your physician choose a Brand drug when a Genenc
equivalent is available The charge is the difference between the cost of the Brand drug and the Genenc drug This additional charge must be
paid m addition to the applicable Brand copayment (Preferred or Non Preferred)
Generic drug means a drug which has the same active ingredient as a Brand drug or is identified as a Genenc drug by AvMed
Participating Pharmacy means a pharmacy (either Retail Mail Order or Specialty Pharmacy) which has entered into an agreement with AvMed
to provide Prescnption Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy
Preferred Drug List means the Preferred Brand medications as determined by AvMed s Pharmacy and Therapeutics Committee based on
clinical efficacy relative safety and cost in comparison to similar medications withm a therapeutic class This three tiered list establishes three
levels of copayment for medications within therapeutic classes Therapeutic classes not regulated by a three-tier schedule are considered open
As new medications in a regulated therapeutic class become available they may be considered excluded until they have been reviewed by
AvMed s Pharmacy and Therapeutics Committee
Prescription Drug means a medication which has been approved by the Food and Drug Admmistration and which can only be dispensed
pursuant to a Prescnption according to state and federal law
Pre Authorization means the process of obtaining approval for certain Prescription Drugs (pnor to dispensing) according to AvMed s
guidelines The approval must be obtained from AvMed by the prescnbing Physician The list of Prescnption Drugs requiring Pre Authorization
is subject to penodic review and modification by AvMed A copy of the list of medications requiring authonzation and the applicable cntena are
available from Member Services
Quantity Limits are set in accordance with Food and Drug Administration (FDA) approved prescnbing limitations general practice guidelines
supported by medical specialty organizations and/or evidence based, statistically valid clinical studies without published conflicting data This
means that a medication specific quantity limit may apply for medications that have an increased potential for over utilization or an increased
potential for a member to expenence an adverse effect at higher doses
HOW DOES RETAIL PRESCRIPTION COVERAGE WORK'
To obtain your prescnption take to or have your physician call an AvMed Pharmacy Network Provider Present your prescnption along with
your AvMed membership card Pay the following copayment (as well as the Brand Additional Charge if you or your physician choose a Brand
product when a Genenc equivalent is available)
Tier 1
Tier 2
Tier 3
Preferred Genenc Drugs
Preferred Brand Drugs
Non Preferred Brand or Genenc Drugs
$ 15 00
$3000
$ 50 00
ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL
Mail service is a benefit option for maintenance medications needed for chronic or long term health conditions It's best to get an initial
prescnption filled at your retail pharmacy Ask your physician for an additional prescnption for up to a 90 day supply of your medication to be
ordered through mail service Up to 3 refills are allowed per prescnption Pay the following copayment (as well as the Brand Additional Charge
if you or your physician choose a Brand product when a Genenc equivalent is available)
Tier 1
Tier 2
Tier 3
Preferred Genenc Drugs
Preferred Brand Drugs
Non -Preferred Brand or Genenc Drugs
$ 45 00
$ 90 00
$ 150 00
Prescription Drug Benefits, continued
WHAT COPAYMENT DO YOU PAY GENERIC, PREFERRED BRAND, OR NON -PREFERRED BRAND OR GENERIC/
You will pay the Generic copayment for Generic medications unless otherwise specified
You will pay the applicable Brand copayment for Preferred Brand medication and Non -Preferred Brand or Genenc medications If you or
your physician request or require a Brand drug when a Generic equivalent drug is available you will be responsible for paying the cost
difference between the Brand and Genenc plus the Brand drug copayment
WHAT IS COVERED/
■ Your prescription drug coverage includes outpatient medications (including oral contraceptives) which require a prescription and are
prescnbed by your AvMed physician in accordance with AvMed s coverage cntena AvMed reserves the nght to make changes in
coverage cntena for covered products and services Coverage cntena are medical and pharmaceutical protocols used to determine
payment of products and services and are based on independent clinical practice guidelines and standards of care established by
government agencies and medical/pharmaceutical societies
• Your retail prescnption drug coverage includes up to a 30 day supply of a medication for the listed copayment The pharmacy will
dispense the quantity sufficient to treat an acute phase of illness or within the drug manufacturer s recommended dosages but not
more than a 30 day supply per copayment Your prescnption may be refilled via retail or mail order after 75% of your previous fill
has been used However pnor authonzation may be required for covered medications
• Your mail-order prescnption drug coverage includes up to a 90 -day supply of a routine maintenance medication for the listed
copayment If the amount of medication is less than a 90 day supply you will still be charged the listed mail order copayment
■ Your prescription drug coverage includes coverage for Depo-Provera, which is an injectable contraceptive There is a copayment of
$30 for each injection If there is an office visit associated with the injection there will be an additional copayment required for the
office visit
QUESTIONS/ Call your AvMed Member Services Department at 1 800-88-AvMed (1 800 882 8633)
EXCUISIONS AND LIMITATIONS
• Drugs or medications which do not require a prescnption (i e over the counter medications) or when a non prescnption alternative is
available
• Medical supplies including therapeutic devices dressings appliances and support garments
• Replacement Prescnption Drug Products resulting from a lost stolen expired broken or destroyed Prescnption Order or Refill
• Diaphragms and other contraceptive devices
• Fertility drugs
■ Medications or devices for the diagnosis or treatment of sexual dysfunction
• Medications for dental purposes including fluonde medications
• Prescnption and non-prescnption vitamins and minerals except prenatal vitamins
• Nutntional supplements
• Blood biologicals and immunizations
• Hypodermic needles synnges injectable and self injectable medications except insulin and insulin needles and synnges glucagon
epinephnne and anticoagulants
■ Injectable drug products (except chemotherapy for cancer patients insulin for diabetic patients allergy serums and any medications
administered by the attending physician, to treat an acute phase of an illness)
• Investigational and expenmental drugs (except as required by Flonda statute)
• Cosmetic products, including hair growth skin bleaching sun damage and anti wnnkle medications
• Nicotine suppressants and smoking cessation products and services
• Prescription and non prescnption appetite suppressants and products for the purpose of weight loss
• Compounded prescnptions except pediatric preparations
■ Medications for non business related travel including Transdermal Scopolamine
Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA
However any medicines that require prior authorization will be treated as a claim for benefits subject to the Claims and Appeals
Procedures as outlined in Section XVI of the Group Medical and Hospital Service Contract
AV G100 RX 15/30/50 OC 03
MP 3450 (10/03)
AvMn
HEALTH PLANS
Amendment
SELF-ADMINISTERED INJECTABLE DRUG BENEFITS
$75 CO -PAYMENT
DEFINITIONS
Self Injectable drug' is a medication that has been approved by the Food and Drug Administration (FDA)
for self-mjection AND is administered by subcutaneous injection OR a medication for which there are
instructions to the patient for self -injection in the manufacturer's prescnbing information (package insert)
WHAT IS COVERED?
Your self -injectable drug coverage extends to many injectable drugs approved by the FDA for
injection These drugs must be prescnbed by a physician and dispensed by an AvMed Retail or
Specialty Pharmacy AvMed reserves the nght to make changes m coverage cntena for covered
products and related services Coverage cntena are medical and pharmaceutical protocols used
to determine payment of products and services and are based on independent clinical practice
guidelines and standards of care established by government agencies and
medical/pharmaceutical societies
Pre-authonzation is required for all self injectable drugs
Your self -injectable drug prescription coverage includes the quantity sufficient to treat the acute
phase of an illness or established by the manufacturers dosing guidelines but not more than a 30
day supply per Co -payment of $75 or actual cost, whichever is less
The Co -payment levels for self-administered injectable drugs apply regardless of provider This
means that you are responsible for the appropnate Co -payment whether you receive your self-
administered injectable drug from the pharmacy, at the doctor's office or during home health
visits
- If you request a brand drug when a genenc equivalent is available, you will be responsible for
paying the cost difference between the Brand and Genenc drugs in addition to the applicable
Co -payment
Discuss your prescription with your Physician or Pharmacist to be sure that you know what the prescnption
is for, how to administer it correctly, what results are expected and in what timeframe
EXCLUSIONS AND LIMITATIONS
All exclusions and limitations listed on your Prescnption Drug coverage remain in force unless
specifically addressed herein
AV G100 IDB $75 04
MP 3477 (11/04)
AvMED
HEALTH PLANS
Amendment
Inpatient Mental Health and Partial Hospitalization Benefits
As of the effective date Inpatient Mental Health and Partial Hospitalization Benefits are being provided for an additional
premium
• Inpatient treatment of mental/nervous disorders for up to 30 days per patient, subject to a member copayment of $250
per admit shall be provided by the Plan when a member is admitted to a Participating Hospital or Participating Health
Care Facility as a registered bed patient
• Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient
hospitalization and is combined with the inpatient hospital benefit Two days of Partial Hospitalization will count as
one day toward the inpatient Mental Health Benefit subject to member copayment as noted above
AV G100-MH/PH $250 per admit 04
MP 3522 (10/04)
HEALTH PLANS
Amendment
Substance Abuse Benefits
As of the effective date the following Substance Abuse Benefits have been added for an additional
premium
• INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute
detoxification
• OUTPATIENT An intensive treatment program(s) of one or more weeks by Plan Physicians
subject to a member copayment of $50 per week Coverage is limited to a
maximum of six weeks per contract year
AV SA R 98
MP 1527 (1/04)
AvMm
HEALTH PLANS
Durable Medical Equipment
Amendment
If selected, the following coverage is hereby modified, for an additional premium
DURABLE MEDICAL EQUIPMENT
• Benefits are limited to a maximum of $2,000 per contract year
All other coverage provisions, including copayment, limitations and exclusions remain as stated in the Certificate of
Coverage or Schedule of Co -Payments
*In the treatment of diabetes, coverage for an infusion pump will apply toward the annual maximum limitation but
shall not be subject to the durable medical equipment benefit limitation
AV G100 DME 2000 R 01
MP 2149(1/04)
AvMa
HEALTH PLANS
OUTPATIENT VISION BENEFITS
Amendment
As of the effective date the following benefits are added for an additional premium
The Plan provides one routme vision examination per contract year with no age limitation subject to a member
copayment of $10 per visit No pre authonzation or referral is necessary but services must be provided by a Plan
Physician
The Plan provides one (1) pair eyeglasses per contract year subject to a member copayment of $10 The eyeglasses
must be non treated standard single or bifocal lenses only with standard frame from the available selection (designer
frames are not covered)
AV VISION R 99
MP 2043 (1/04)
HEALTH PLANS
Amendment
Coverage for Mammograms - Waiver of Copayment
If selected the following provision is hereby modified for an additional premium
Section 10 27 of the AvMed Health Plan Group Medical and Hospital Service Contract is amended to state
Mammograms are covered in accordance with Florida Statutes one baseline mammogram is covered for
female Members between the ages of 35 and 39 a mammogram is available every two years for female
Members between the ages of 40 and 49 and a mammogram is available every year for female Members
aged 50 and older
In addition one or more mammograms a year are available when based upon a Physician s
recommendation for any woman who is at risk for breast cancer because of a personal or family history of
breast cancer because of having a history of biopsy proven benign breast disease because of having a
mother sister or daughter who has had breast cancer or because a woman has not given birth before the
age of 30 This coverage will not be subject to diagnostic imaging copayments
AV Mammogram R 02
MP -3228 (1/04)
HEALTH PLANS
Amendment
DOMESTIC PARTNER
As of the Effective Date Part IV ELIGIBILITY of the Group Medical and Hospital Service Contract is
amended by the addition of the following provision
Dependent Eligibility will be added for a Domestic Partner and his or her children
Definition of Domestic Partner
A Domestic Partner means an unmarried adult who
• Cohabits with you in an emotionally committed and affectional relationship that is meant to be of
lasting duration
• Is not related by blood or marriage,
• Is at least eighteen years of age
• Is mentally competent to consent to a contract
• Has filed a Domestic Partnership agreement or registration with the Employer if available in the state
(and/or city) of residence
• Has shared financial obligations including basic living expenses for the twelve month penod pnor to
enrollment in the plan
• Will provide documentation that will be satisfactory to the Employer as evidence of a Domestic
Partner relationship and
• Meets the dependents eligibility requirements of the Employer s health benefits plan
AV DP 12 R 02
MP 3147 (1/04)
AvMiii
HEALTHPLANS
ELECTIVE TERMINATION OF PREGNANCY
Amendment
If selected, the following optional coverage is hereby added
The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state
• Elective termination of pregnancy will be a covered benefit if the services and treatment are
provided by an AvMed participating provider in an AvMed participating facility There shall be a
physician copayment of $100 00 in addition to the applicable facility copayment
AV G100 ETP R 97
MP 1321 (1/04)
AvMED
HEALTH PLANS
VILLAGE OF KEY BISCAYNE - Group Selection Amendment
As of the Effective Date the above -named Subscnbmg Group has selected the following Amendments
Identifier
AV -G100 RX 15/30/50 OC 03
AV G 100-IDB-$75-04
AV G100 MH/PH $250 per admit 04
AV SA -R 98
AV G 100-DME 2000-R-01
AV VISION R-99
AV MAMMOGRAM R 02
AV DP 12-R-02
AV G100 ETP-R-97
Amendment Name
Prescnption Drug Benefits
Injectable Drug Benefits
Mental Health Benefits
Substance Abuse Benefits
Durable Medical Equipment
Outpatient Vision Benefits
Coverage for Mammograms
Domestic Partner Benefits
Elective Termination of Pregnancy
The provisions contained m the Schedule of Co -payments applicable to this Contract and all Exhibits and
Riders 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 is May 1 2005
Subscribing Group
VILLAGE OF KEY BISCA
By
Signature
C G, d CC, c n c
Name
!% CAGe /tfA ✓a q eZ
Title
Date
AV -
bloc
Isle,,ende Z --
-SELECTION AMENDMENT -03
AVMED Inc
d/b/a AVME P eal Plan
By
Signatur
Evis Clavareza
Name
Director of Client Service
Title
Date
2/°