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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/°