HomeMy Public PortalAboutAgreement 05-01-06 - 04-30-07AvMed Health Plans
Group Medical
and
Hospital
Service
Contract
AV G100 2005
MP 3699 (10/05)
TABLE OF CONTENTS
SERVICE AREAS 1
I GENERAL 1
II INTERPRETATION 1
III DEFINITIONS 2
IV ELIGIBILITY 8
V ENROLLMENT 10
VI EFFECTIVE DATE OF MEMBERSHIP 10
VII MONTHLY PAYMENTS AND CO PAYMENTS 12
VIII CONVERSION 13
IX TERMINATION 15
X SCHEDULE OF BASIC BENEFITS 22
XI LIMITATIONS OF BASIC BENEFITS 30
XII EXCLUSIONS FROM BASIC BENEFITS 31
XIII COORDINATION OF BENEFITS 35
XIV REIMBURSEMENT 38
XV DISCLAIMER OF LIABILITY 38
XVI GRIEVANCE PROCEDURE 39
XVII MISCELLANEOUS 45
AV G100 2005
MP 3699 (10/05)
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
Miami -Dade
FT LAUDERDALE
13450 W Sunrise Boulevard
Suite 370
Sunrise Florida 33323 2947
(954) 462-2520
(800) 368 9189
Broward
Palm Beach
JACKSONVILLE
1300 Riverplace Boulevard
Suite 200
Jacksonville Florida 32207
(904) 858-1300
(800) 227-4184
Baker
Clay
Duval
Nassau
St Johns
GAINESVILLE
4300 N W 89th Boulevard
Post Office Box 749
Gainesville Florida 32606 0749
(352) 372 8400
(800) 346 0231
Alachua
Bradford
Citrus
Columbia
Dixie
Gilchrist
Hamilton
Levy
Marion
Suwannee
Union
ORLANDO
541 South Orlando Avenue
Suite 205
Maitland Florida 32751
(407) 539 0007
(800) 227-4848
Orange
Osceola
Seminole
TAMPA BAY/ SOUTHWEST
FLORIDA
1511 North Westshore Boulevard
Suite 450
Tampa Florida 33607
(813) 281-5650
(800) 257-2273
Hernando
Hillsboro
Lee
Pasco
Pinellas
Polk
Sarasota
AVMED MEMBER SERVICES - ALL AREAS
1-800-88 AVMED
(1-800-882-8633)
AV G100 2005
MP 3699 (10/05)
AvMed, INC
d/b/a AvMed HEALTH PLANS
GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT
IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein
and of mutual promises and benefits hereinafter described AvMed Inc a Florida corporation d/b/a
AvMed Health Plans (hereinafter referred to as "AvMed"), and
(hereinafter referred to as "Subscribing Group") agree as follows
I GENERAL
The Subscribing Group engages AvMed Health Plans on behalf of the group health plan described herein
(the Plan") to arrange for the provision of Medical Services or benefits which are Medically Necessary
for the diagnosis and treatment of Members of the Subscribing Group through a network of contracted
independent physicians and Hospitals and other independent health care providers who are not agents or
employees of AvMed (see Section 15 04) AvMed in so arranging for the delivery of Medical Services
or benefits, does not directly provide these Medical Services or benefits AvMed arranges for the
provision of said services in accordance with the covenants and conditions contained in this Contract
AvMed shall rely upon the statements of the Subscriber in his application in providing coverage and
benefits hereunder
This Contract is not intended to and does not cover or provide any Medical Services or benefits that are
not Medically Necessary for the diagnosis and treatment of the Member The determination as to which
services are Medically Necessary shall be made by AvMed subject to the terms and conditions of this
Contract
AvMed reserves the right to make changes in coverage criteria for covered products and services
Coverage criteria 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
The Medical and Hospital Services covered by this Contract shall be provided without regard to the race
color religion physical handicap or national origin of the Member in the diagnosis and treatment of
patients in the use of equipment and other facilities or in the assignment of personnel to provide
services pursuant to the provisions of Title VI of the Civil Rights Act of 1964 as amended and the
Americans with Disabilities Act of 1990
II INTERPRETATION
In order to provide the advantages of Hospital and medical facilities and of the Participating Providers
AvMed operates on a direct service rather than indemnity basis The interpretation of this Contract shall
be guided by the direct service nature of AvMed's program and the definitions and other provisions
contained herein
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III DEFINITIONS
As used in 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 in part, for a benefit, including 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 in the Plan a denial, reduction or termination of, or a failure
to provide or make payment (in whole or in part) of, a benefit resulting from the application of
any Utilization 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 "AvMed, ' means a private not for profit Florida 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 this Contract made by a Member in accordance with
AvMed s procedures for filing benefit claims, including Pre Service Claims and Post -Service
Claims
3 04 "Claimant" means a Member or a Member s authorized representative acting on behalf of the
Member AvMed may establish procedures for determining whether an individual 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 authorized 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 ongoing course of treatment to be provided over a period of time
or number of treatments that was previously approved by AvMed
3 06 "Contract" means this Group Medical and Hospital Service Contract which may at times be
referred to as "Group Contract" or "Subscribing Group Contract" and all applications rate
letters, face sheets, riders, amendments, addenda exhibits, supplemental agreements, and
schedules which are or may be incorporated in this Contract from time to time
3 07 "Contract Year" means the period of 12 consecutive months commencing on the effective date
of this Contract
3 08 "Conversion Contract" means an individual Member or Subscriber contract which shall be
available to continue coverage (as provided for therein) of the Subscriber or the Dependent of the
Subscriber upon termination of the Subscribing Group Contract as provided in Part VIII of this
Contract and shall at times be referred to as the "Individual Conversion Contract "
3 09 "Co -payment" means the charge, in addition to the prepaid premium charges, which the
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 Member is
responsible for the payment of any Co -payment charges directly to the provider of the health
services at the time of service
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3 10 Custodial Care" means services and supplies that are furnished mainly to train or assist in the
activities of daily living such as bathing feeding dressing walking and taking oral medications
"Custodial Care" also means services and supplies that can be safely and adequately provided by
persons other than licensed health care professionals, such as dressing changes and catheter care,
or that ambulatory patients customarily provide for themselves such as ostomy care
administering insulin and measuring and recording urine and blood sugar levels
3 11 "Dental Care" means dental x-rays examinations and treatment of the teeth or any services
supplies or charges directly related to (i) the care, filling removal or replacement of teeth, or (ii)
the treatment of injuries to or disease of the teeth, gums or structures directly supporting or
attached to the teeth that are customarily provided by dentists (including orthodontics
reconstructive jaw surgery casts splints and services for dental malocclusion)
3 12 "Dependent" means any member of a Subscriber's family who meets all applicable requirements
of Part IV and is enrolled hereunder and for whom the prepayment required by Part VII has
actually been received by AvMed
3 13 "Durable Medical Equipment (DME), Orthotics, and/or Prosthetics" Coverage for DME
orthotics and prosthetics is limited as outlined in Sections 10 20, 10 21 and 10 22 subject to
specific Limitations and Exclusions as listed in Part XII The determination of whether a covered
item will be paid under the DME orthotics or prosthetics benefits 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 manifesting itself by acute symptoms of sufficient severity such
that the absence of immediate medical attention could reasonably be expected to
result in any of the following
a) Serious jeopardy to the health of a patient including a pregnant woman or fetus
b) Serious impairment to bodily functions
c) Serious dysfunction of any bodily organ or part
3 14 02 With respect to a pregnant woman
3 14 03
a) That there is inadequate time to effect safe transfer to another Hospital prior to
delivery
b) That a transfer may pose a threat to the health and safety of the patient or fetus
or
c) That there is evidence of the onset and persistence of uterine contractions or
rupture of the membranes
Examples of Emergency Medical Conditions include but are not limited to heart
attack stroke, massive internal or external bleeding, fractured limbs or severe
trauma
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315 "Emergency Medical Services and Care" means medical screening, examination, and
evaluation by a physician or to the extent permitted by applicable law by other appropriate
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 within the service capability of the
Hospital
3 15 01
3 15 02
In -area emergency does not include elective or routine care care of minor illness or
care that can reasonably be sought and obtained from the Member's Primary Care
Physician The determination as to whether or not an illness or injury constitutes an
emergency shall be made by AvMed and may be made retrospectively based upon all
information known at the time the patient was present for treatment
Out of -area emergency does not include care for conditions for which a Member
could reasonably have foreseen the need of such care before leaving 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 injury constitutes an emergency shall
be made by AvMed and may be made retrospectively based upon all information
known at the time the 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 carrying sufficient credits to qualify as a full
time student in accordance with the requirements of the school (See Subsection 4 02 02(f))
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 in Sections 627 552 (employee groups) 627 553 (debtor groups), 627 554 (labor
union and association groups) and 627 5565 (additional groups) Florida Statutes
3 18 01 The terms "amount of insurance" and "insurance" include the benefits provided under
a plan of self-insurance
3 18 02 The term "insurer" includes any person entity or governmental unit providing a plan
of self-insurance
3 18 03 The terms "policy," "insurance policy," "health insurance policy," and "Group Health
Insurance policy" include plans of self-insurance providing health insurance benefits
3 19 "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 in the delivery of
health care services who are licensed and practice under an institutional license, individual
practice association or other authority consistent with State law and who are Participating
Providers of AvMed Health Plans
3 20 "Home Health Care Services (Skilled Home Health Care)" means services that are provided
for a Member who does not require confinement in a Hospital or Other Health Care Facility Such
services include, but are not limited to, the services of professional visiting nurses or other health
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care personnel for services covered under this Contract See Section 10 08 regarding physical and
occupational therapy Limitations
3 21 "Hospice" means a public agency or private organization that is duly licensed by the State to
provide Hospice services and with whom AvMed has a current provider agreement Such
licensed entity must be principally engaged in providing pain relief, symptom management, and
supportive services to terminally ill Members
3 22 Hospital" means any general acute care facility which is licensed by the State and with which
AvMed has contracted or established arrangements for inpatient Hospital Services and/or
Emergency Medical Services and Care and shall at times be referred to as a "Participating
Hospital "
3 23 "Hospital Services" (except as expressly limited or excluded by this Contract) means those
services for registered bed patients that are
a) Generally and customarily provided by acute care general Hospitals within the Service
Area
b) Performed, prescribed, or directed by Participating Providers, and
c) 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 24 "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 25 "Injectable Drug" means a medication that has been approved by the Food and Drug
Administration (FDA) for administration by one or more of the following routes intramuscular
injection, intravenous injection, intravenous infusion subcutaneous injection intrathecal
injection intrarticular injection intracavernous injection or intraocular injection Pre
authorization is required for Injectable Drugs
3 26 "Limitation" means any provision other than an Exclusion which restricts coverage under this
Contract
3 27 "Master Application" means the Subscribing Group application form entitled "Master
Application" which becomes a part of the Contract when the Master Application has been
completed and executed by the Subscribing Group and AvMed
3 28 "Medically Necessary" means the use of any appropriate medical treatment service equipment
and/or supply as provided by a Hospital, skilled nursing 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
a) Consistent with the symptom diagnosis and treatment of the Member's condition
b) The most appropriate level of supply and/or service for the diagnosis and treatment of
the Member's condition
c) In accordance with standards of acceptable community practice
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d) Not primarily intended for the personal comfort or convenience of the Member the
Member's family, the physician, or other health care providers,
e) 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
f) Not experimental or investigational
3 29 "Medical Office" means any outpatient facility or physician's office in the Service Area utilized
by a Participating Provider
3 30 "Medical Services" (except as limited or excluded by this Contract) means those professional
services of physicians and other Health Professionals, including medical, surgical, diagnostic
therapeutic, and preventive services, that are
a) Generally and customarily provided in the Service Area
b) Performed prescribed or directed by Participating Providers and
c) Medically Necessary (except for preventive services as stated herein) for the
diagnosis and treatment of injury or illness
3 31 "Member" means any Subscriber or Dependent, as described in Part III, Sections 3 12 and 3 43,
of this Contract
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 AvMed has neither made
arrangements nor contracted to render the professional health services set forth herein as a
Participating Provider
3 33 "Other Health Care Facihty(ies)" means any licensed facility, other than acute care Hospitals
and those facilities providing services to ventilator dependent patients which provides inpatient
services such as skilled nursing care or rehabilitative services for which AvMed has contracted or
established arrangements for providing these services to Members Coverage is limited 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 Facility with whom AvMed has made
arrangements or contracted to render the professional health services set forth herein
3 35 "Participating Physician" means any Participating Provider licensed under Chapter 458
(physician) 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes "Attending
Physician" means the Participating Physician primarily responsible for the care of a Member
with respect to any particular injury or illness
3 36 "Post -Service Claim" means any Claim for benefits under the Plan that is not a Pre Service
Claim
3 37 "Pre -Service Claim" means any Claim for benefits under the Plan with respect to which in
whole or in part a Member must obtain authorization from AvMed in advance of such services
being provided to or received by the Member
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3 38 Primary Care Physician" means a Participating Provider physician engaged in family practice
pediatrics internal medicine obstetrics/gynecology or any specialty physician from time to time
designated by AvMed as a "Primary Care Physician" in AvMed's current list of physicians and
Hospitals
3 39 "Relevant Document" means any documentation that
a) Was relied upon in making the benefit determination
b) Was submitted considered or generated in the course of making the benefit
determination, without regard to whether it was relied upon in making the
determination,
c) Demonstrates compliance with the administrative process and
d) Constitutes a statement of policy or guidance with respect to the Plan concerning
the Adverse Benefit Determination for the Claimant s diagnosis without regard to
whether such advice or statement was relied upon in making the Adverse Benefit
Determination
3 40 "Self -Administered Injectable Drug" means a medication that has been approved by the FDA
for self -injection and is administered by subcutaneous injection or a medication for which there
are instructions to the patient for self injection in the manufacturer s prescribing information
(package insert)
3 41 "Service Area" means those counties in the State of Florida where AvMed has been approved to
conduct business by the Florida Department of Financial Services
3 42 "Specialty Health Care Physician" means any Participating Physician licensed under Chapter
458 (physician), 459 (osteopath) 460 (chiropractor) or 461 (podiatrist) Florida Statutes other
than the Member's chosen Primary Care Physician
3 43 "Subscriber" means a person who meets all applicable requirements of Section 4 01 enrolls in
the Plan and for whom the premium prepayment required by Part VII has actually been received
by AvMed
3 44 "Subscribing Group" means a corporation partnership limited liability company or other legal
entity (and its wholly owned subsidiaries) that negotiates and agrees to contract for the health
services and benefits provided herein for its eligible employees
3 45 "Total Disability" means a totally disabling condition resulting from an illness or injury which
prevents the Member 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 is under the regular care of a physician
3 46 "Urgent Care Claim" means any Claim for medical care or treatment that could seriously
jeopardize the Member's life or health or the Member s ability to regain maximum function or in
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
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made by an individual acting on behalf of AvMed applying the judgment of a prudent layperson
who possesses an average knowledge of health and medicine 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 47 "Urgent Care/Immediate Care" means medical screening, examination and evaluation
received in 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 injury or disability if left untreated
3 48 "Utilization Management Program" means those comprehensive initiatives that are designed to
validate medical appropriateness and to coordinate covered services and supplies These include
but are not limited to (1) concurrent review of all patients hospitalized in acute care psychiatric
rehabilitation and skilled nursing facilities, including on site review when appropriate, (2) case
management and discharge planning for all inpatients and those requiring continued care in an
alternative setting (such as home care or a skilled nursing facility) and for outpatients when
deemed appropriate, and (3) the Benefit Coordination Program which is designed to conduct
prospective reviews for select medical services to ensure that services are covered and Medically
Necessary The Benefit Coordination Program may also advocate alternative cost effective
settings for the delivery of prescribed care and may identify other options for non covered health
care needs
3 49 "Ventilator Dependent Care Unit" means care received in any facility which provides services
to ventilator dependent patients other than acute Hospital care including 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 in a free standing facility or maintained in
a Hospital or skilled nursing facility setting Coverage is limited to 100 days lifetime maximum
IV ELIGIBILITY
4 01 To be eligible to enroll as a Subscriber a person must be
4 01 01
An employee of the Subscribing 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 in the Service Area Except as provided for Emergency
Medical Services and Care, the covered services and benefits are available only
from Participating Providers
4 01 02 Employed for the period of time required for eligibility as set forth in the Master
Application, and
4 01 03 Entitled on his own behalf to participate in the medical and Hospital care benefits
arranged by the Subscribing 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 Subscriber, a new spouse must be enrolled within 31 days after
marriage in order to be covered, or
4 02 02 A child of the Subscriber or a child of a covered Dependent of the Subscriber
provided that the following conditions apply
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a) The child is the natural child or stepchild of the Subscriber, a legally adopted
child in the custody of the Subscriber from the time of placement in the home
(written evidence of adoption must be furnished to AvMed upon request) a child
for whom the Subscriber 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 Subscriber (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 Subscriber for maintenance and
support and is not regularly employed by one or more employers for a total of 30
hours or more per week
e) The child is not married
0 The child is age 19 or over but under the age of 23 or other limiting age as
specified by the parties in a fully executed addendum to this Contract and is
enrolled as a Full Time Student (see Section 3 17) at a college university
vocational or secondary school Subscriber is responsible for notifying AvMed
when full time attendance commences or terminates, and coverage shall
commence or terminate upon such notification Termination of coverage will be
retroactively applied if AvMed is not notified Subscriber agrees to provide
documentation of Full Time Student status upon request by AvMed
g)
The child is age 19 or over and is wholly dependent on the Subscriber 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 when the Subscriber is obligated to provide medical
care by a qualified medical child support order You (or your beneficiaries) may
obtain without charge copies of the Plan s procedures governing qualified
medical child support orders and a sample qualified medical child support order
by contacting the Plan Administrator
i) In the case of a newborn child AvMed should be notified in writing prior to the
scheduled delivery date of the Subscriber's intention to enroll the newborn child
but such notice shall not be later than 31 days after the birth If timely notice is
provided, no additional premium will be charged for the additional coverage of
the newborn during the 31 day period following 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 period of the Subscribing Group
All services applicable for covered Dependent children under this Contract shall be
provided to an enrolled newborn child of the Subscriber or to the enrolled newborn child
of a covered Dependent of the Subscriber or to the newborn adopted child of the
Subscriber provided that a written agreement to adopt such child has been entered into
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(prior to the birth of the child) from the moment of birth (as provided in 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 in the Subscriber's residence in compliance
with Florida law
Coverage for the newborn child of a covered Dependent of the Subscriber (other than the
spouse of the Subscriber) shall terminate 18 months after the birth of the newborn child
4 03 No person is eligible to enroll hereunder who has had his coverage previously terminated under
Part IX Subsection 9 01 05 except with the written approval of AvMed
4 04 Attainment of the limiting 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
a) Incapable of self-sustaining employment by reason of mental retardation or
physical handicap and
b) Chiefly dependent upon the Subscriber for support and maintenance provided
proof of such incapacity and dependency is furnished to AvMed by Subscriber
within 31 days of the child's attainment of the limiting age and subsequently as
may be required by AvMed but not more frequently than annually after the two
year period following the child's attainment of the limiting age
4 05 During the term of this Contract no changes in the Subscribing Group eligibility or requirements
of participation shall be permitted to effect eligibility or enrollment under this Contract unless
such change is agreed to by AvMed
V ENROLLMENT
5 01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof
AvMed may allow an open enrollment period of 31 days in which any eligible Subscriber on
behalf of himself and his Dependents may elect to enroll in the 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 31 days after becoming
eligible by submitting application forms acceptable to or provided by AvMed otherwise the
eligible Subscribers and Dependents may not enroll until the next open enrollment period of
Subscribing Group
5 03 Special Enrollment Periods An eligible Subscriber or Dependent may request to enroll in the
Plan outside of the initial enrollment and annual open enrollment periods if that individual within
the immediately preceding 31 days was covered under another employer health benefit plan as an
employee or the dependent of an employee at the time he was initially eligible to enroll for
coverage under the Plan, and
5 03 01 Demonstrates that he or his Dependent has experienced one of the following status
change events including
a) Marriage,
b) Birth, adoption or placement for adoption
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c) Legal separation, divorce or annulment,
d) Change in legal custody or legal guardianship
e) Death,
f) Relocation into or out of the Service Area
g) Termination/commencement of employment
h) Reduction in the number of hours of employment,
i) Commencement of or return from leave of absence,
j) Change in employment status
k) Change in worksite
1) Strike or lockout
m) Termination of employer contributions toward such coverage,
n) Exhaustion of COBRA coverage
o) Attainment of lifetime maximum and
5 03 02 Requests enrollment within 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 in Part IV shall at all times control and no coverage contrary
thereto shall be effective Coverage shall not be implied due to clerical or administrative errors if
such coverage would be contrary to Part IV (Also see Section 17 10)
5 05 This Contract at the sole option of AvMed will not be accepted if at the time of initial offering to
Subscribing Group or following re enrollment the total enrollment does not result in a
predetermined minimum enrollment as established by AvMed The required minimum group
enrollment is included in the rate letter submitted to Subscribing Group
VI EFFECTIVE DATE OF MEMBERSHIP
Subject to the payment of applicable monthly premium charges set forth in Part VII and to the provisions
of this Contract coverage under this Plan shall become effective on the following dates
6 01 Eligible Subscribers and Dependents who enroll during the open enrollment period will be
covered Members as of the effective date of this Contract or subsequent anniversary thereof
6 02 If a Subscriber acquires an eligible Dependent through birth adoption placement for adoption or
marriage such Dependent shall be treated as covered under the Plan if within 31 days (or as
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otherwise provided for newborns in Part IV) of acquiring the new Dependent you complete and
submit an enrollment form on behalf of such Dependent If received by AvMed within the 31
day time period (or 60 days as permitted for newborns), the enrollment for such Dependent shall
become effective on the date of the birth adoption or placement for adoption or in the case of
marriage on the first day of the month following the date of marriage During this period you
and your eligible spouse may also enroll for medical coverage under the Plan if not already
covered However, if an enrollment request is not received by AvMed within the required time
frame you and your eligible Dependents will be required to wait until the next open enrollment
period to apply for coverage
6 03 If you or your Dependents originally declined 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 in the Plan To enroll you must properly
complete an enrollment form within 31 days of the loss of such other coverage or the termination
of employer contributions The effective date of any coverage provided by AvMed will be the
first day of the month following the date you enroll If you fail to enroll within 31 days after the
loss of other coverage you must wait until the next open enrollment period to apply for coverage
6 04 Coverage for the newborn child of the Subscriber or the newborn child of the Subscriber's
covered Dependent is effective at birth if Subsection 4 02 02(i) and Section 6 02 are complied
with
VII MONTHLY PAYMENTS AND CO -PAYMENTS
7 01 On or before the first day of each month for which coverage is sought Subscribing Group or its
designated agent shall remit to AvMed on behalf of each Subscriber 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 AvMed 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 Subscribing Group to pay the premium due by the first of the month and not later than the end
of the grace period (as provided in Section 7 02) shall result in retroactive termination of the
Subscribing Group effective at 12 00 a m (midnight) on the last day of the month for which the
premium was paid unless the payment of premiums has otherwise been contractually adjusted
and specified by the parties in a fully executed addendum to this Contract An additional charge
will apply to all late premium payments (See Section 17 14)
7 02 Grace Period This Contract has a ten-day grace period This provision means that if any
required premium is not paid on or before the date it is due it must be paid during the following
grace period During the grace period, the Contract will stay in force However if payment is
not received by the last day of the grace period, termination of this Contract for nonpayment of
the premium will be retroactive to 12 00 a m (midnight) on the last day of the month for which
the 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 described in your Schedule of
Benefits The Co -payment limits apply to Co -payments made for all core benefits contained in
this Contract and do not apply to services provided under the Prescription Drug Mental Health
Substance Abuse, Vision and other supplemental riders
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7 04 Member shall pay premiums, applicable supplemental charges or Co payments as provided in
this Contract If the Member fails to pay the applicable premiums, upon ten days written notice
from AvMed to Member the Member's rights hereunder shall be terminated Consideration for
reinstatement with AvMed shall require a new application, and any re enrollment shall be at the
sole discretion of AvMed and shall not be retroactive
7 05 Refund of premiums paid to AvMed by the Subscribing 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 premium amounts paid up to a maximum of 60 days from the date of such ineligibility or
termination provided there are no claims incurred subsequent to the effective date of termination
No retroactive terminations of Members will be made beyond 60 days from notification of the
terminating event
7 06 In the event of the retroactive termination of an individual Member (as described in Subsections
9 01 02 and 9 02 01 of this Contract) AvMed shall not be responsible for medical expenses
incurred by AvMed in providing benefits to the Member under the terms of this Contract after the
effective date of termination (due to the Subscribing Group's nonpayment of premiums or failure
to timely notify AvMed of Member ineligibility) At the discretion of AvMed and based on the
facts available at the time AvMed may pursue either the Subscribing Group or the Member for
payment
VIII CONVERSION
8 01 A Subscriber or covered Dependent whose coverage under the Subscribing Group Contract has
been terminated for any reason including discontinuance of the Subscribing Group Contract in its
entirety or with respect to a covered class and who has been continuously covered under the
Subscribing Group Contract, and under any group health maintenance contract providing similar
benefits which it replaces for at least three months immediately prior to termination shall be
entitled subject to the exceptions contained herein to have issued to him or her a Conversion
Contract (See Section 3 08) unless there is a replacement of discontinued group coverage by
similar group coverage within 31 days
8 01 01
8 01 02
The converting Subscriber and each of the eligible Dependents of the Subscriber who
are converting must be Members of the Plan in good standing on the date when their
coverage terminates under this Group Contract and all such Subscribers and
Dependents after complying with Subsection 8 01 02 below, shall be covered under
the Individual Conversion Contract
A completed status change form requesting conversion shall be sent to AvMed or its
designated administrator with the first applicable premium and shall be received by
AvMed or its designated administrator not later than 63 days after the date of
termination of this Group Contract
8 01 03 Dependents may not convert without the Subscriber except
a) In the event of the death of the Subscriber Dependents are permitted an
automatic conversion privilege and must comply with 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
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himself, by reason of ceasing 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 written evidence of financial
dependence upon request of AvMed
8 01 04
Payment for health care services rendered to a Member after termination and prior to
conversion shall be the responsibility of the Member When the conversion
application has been timely completed (within 63 days after termination of the Group
Contract) and the first premium due has been paid, AvMed shall reimburse the
Subscriber for any payment made by the Subscriber for covered Medical Services
under the converted Contract
8 01 05 A new Conversion Contract is established upon application and payment of the
premium on the day following the Member's termination from group coverage (due
to ineligibility under the Group Contract) and continues through the end of the
calendar year The Contract Year upon renewal shall be the calendar year
8 02 Individual Conversion Contracts may not include supplemental benefits notwithstanding the
supplemental benefits included under this Subscribing Group Contract and may in other respects
as determined by AvMed, differ from this Group Contract
8 03 The conversion privilege will not apply to a Subscriber or covered Dependent if termination of
his coverage under this Contract occurred for any of the following reasons
a) 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,
b) Replacement of any discontinued group coverage by similar group coverage within 31
days
c) Fraud or material misrepresentation in applying for any benefits under this Contract,
(See Subsection 9 01 05)
d) Willful and knowing misuse of AvMed's identification card by the Subscriber
e) Willfully and knowingly furnishing incorrect or incomplete information to AvMed for
the purpose of fraudulently obtaining coverage or benefits from AvMed, or
f) Termination from coverage under this Contract in 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 Reconciliation Act of 1986 (COBRA) expires, the Subscriber or
covered Dependent may be eligible for conversion coverage and may apply by completing an application
for an Individual Conversion Contract, subject to the conditions described in this Part VIII The eligible
Subscriber or Dependent must send a completed application and the applicable premium payment,
postmarked not later than 63 days after the termination of COBRA coverage directly to
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AvMed Health Plans
Accounts Receivable Department
Suite 510
9400 South Dadeland Blvd
Miami Florida 33156
The Subscriber or Dependent may obtain an application form and a statement of current premium rates
for the Individual Conversion Contract by calling AvMed Member Services
It is the responsibility of the Subscribing Group to notify Subscriber of Subscriber's rights under COBRA
For any specific questions concerning COBRA, contact the Subscribing Group
IX TERMINATION
All rights and benefits under this Contract shall cease as of the effective date of termination unless
otherwise provided herein
This Contract shall continue in effect for one year from the effective date hereof and may be renewed
from year to year thereafter subject to the following termination provisions All rights 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 in Part IV
including but not limited to the permanent relocation outside the Service Area
coverage shall automatically terminate on the last day of the month for which the
monthly premium was paid and during which the Subscriber 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 Subscriber's
eligibility, as defined in Part IV
9 01 02
Failure to Make Premium Payment - Upon failure of the Subscribing Group to make
payment of the monthly premium provided in Part VII within ten days following the
due date specified herein benefits hereunder shall terminate for all Subscribers and
any Dependents for whom such payment has not been received at 12 00 am
(midnight) on the last day of the month for which the monthly premium was paid
AvMed regarding cancellation or non renewal of this coverage, may retroactively
cancel the policy to the date for which the Subscribing Group's premiums have been
paid when AvMed provides notice of cancellation or non renewal to the Subscribing
Group prior to 45 days after the date the premium was due AvMed will include a
reason for the Contract termination in its written notification to the Subscribing
Group The Subscribing Group will forward such notification to all Subscribers
when AvMed has notified the Subscribing Group of the cancellation or non -renewal
and AvMed is deemed to have complied with its notification requirements by
providing said notice to the Subscribing Group
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9 01 03
9 01 04
Termination of Group Contract by Subscribing Group — Subscribing Group may
terminate this Group Contract on the anniversary date by giving written notice to
AvMed 15 days prior to Contract anniversary date In such event, benefits hereunder
shall terminate for all Members at 12 00 a m (midnight) on Contract expiration date
Termination of Group Contract by AvMed - AvMed may non -renew or discontinue
this Group Contract based on one or more of the conditions listed below In such
event benefits hereunder shall terminate for all Members at 12 00 a m (midnight) on
the Contract expiration date as described below
a) Subscribing Group has failed to pay premiums or contributions in accordance
with the terms of this Contract or AvMed 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 AvMed
b) Subscribing Group has performed an act or practice that constitutes fraud or
made an intentional misrepresentation of material fact under the terms of this
Contract This will result in immediate termination of Subscribing Group
c) Subscribing Group has failed to comply with a material provision of the Contract
that relates to rules for employer contributions or group participation
Termination will be effective upon 45 days written notice from AvMed to
Subscribing Group
d) There is no longer any enrollee in connection with the Plan who lives, resides, or
works in the Service Area Termination of coverage will be effective on the last
day of the month for which payments were received by AvMed
e) AvMed ceases to offer coverage in the applicable market AvMed will provide
written notice to Subscribing Group at least 180 days prior to such termination
9 01 05 Termination of Coverage for Cause AvMed may terminate any Member
immediately upon written notice for the following reasons which lead to a loss of
eligibility of the Member
a) fraud, material misrepresentation, or omission in applying for membership,
benefits or coverage under this Contract However relative to a misstatement in
the Application after two years from the issue date, only fraudulent
misstatements in the Application may be used to void the policy or deny any
claim for a loss occurred or disability starting after the two year period
b) misuse of AvMed's identification card furnished to the Member
c) furnishing to AvMed incorrect or incomplete information for the purpose of
obtaining membership, coverage or benefits under this Contract
d) behavior which is disruptive, unruly, abusive, or uncooperative to the extent that
the Member's continuing coverage under this Contract seriously impairs AvMed's
ability to administer this Contract or to arrange for the delivery of health care
services to the Member or other Members after AvMed has attempted to resolve
the Member's problem
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At the effective date of such termination premium payments received by AvMed
on account of such termination shall be refunded on a pro rata basis, and AvMed
shall have no further liability or responsibility for the Member under this
Contract
9 02 Notification Requirements
9 02 01
Loss of eligibility of Subscriber It is the responsibility of Subscribing Group to
notify AvMed in writing within 31 days from the effective date of termination
regarding any Subscriber and/or Dependent who becomes ineligible to participate in
the Plan Failure of the Subscribing 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 the premium was paid and during which the Subscriber 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 AvMed in writing within 31
days of the Dependent becoming ineligible
9 02 03 Contract Termination In the event this Contract is terminated the Subscribing
Group agrees that it shall provide 45 days prior written notification of the date of
such termination to its employee Subscribers 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 terminating 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 Continuation Coverage under COBRA Under certain provisions of COBRA the Subscriber or
his Dependents may elect continued coverage under the Plan if coverage is lost due to a
qualifying event
9 04 01 Eligibility You or your covered Dependents will become eligible for continuation
coverage under COBRA after any of the following qualifying events result in the loss of
Plan coverage
a) loss of benefits due to a reduction in your hours of employment
b) termination of your employment including retirement but excluding termination for
gross misconduct,
c) termination of employment following leave under the Family and Medical Leave Act
of 1993 (FMLA) in 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
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d) you or a Dependent first become entitled to Medicare or covered under another group
health plan prior to your loss of coverage due to termination of employment or
reduction in hours
9 04 02 In addition, your Dependents will become eligible for COBRA continuation coverage
after any of the following qualifying 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
termination of employment or reduction in 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
during the continuation coverage period has the same continuation coverage rights as
a Dependent child described above
9 04 03 Notification If a qualifying 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 continue Plan coverage, you must return the election form within 60 days from
the later of the date you receive the form, or the date your coverage ends due to a
qualifying 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
Administrator that a qualifying event has occurred This notification must be
received by the Plan Administrator within 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 right to continue coverage for you and your Dependents
After receiving this notice, the Plan Administrator will send you an election form
within 14 days If you or your Dependents wish to elect continuation coverage the
election form must be returned to the Plan Administrator within 60 days from the
later of the date you receive the form or the date your coverage ends due to the
qualifying 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% administrative fee for the duration of COBRA continuation coverage
If you or your Dependent is Social Security disabled (Social Security disability
status must occur as defined by Title II or Title XVI of the Social Security Act) you
may elect to continue 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 your hours are reduced You must pay 102% of the cost of coverage
for the first 18 months of COBRA continuation coverage and 150% of the cost of
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coverage for the 19th through the 29th months of coverage The Social Security
disability date must occur within the first 60 days of loss of coverage due to your
termination of employment or reduction in hours
For COBRA coverage to remain in effect, payment must be received by the Plan
Administrator 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 continue coverage and it
must cover the period of time back to the first day of your COBRA continuation
coverage )
9 04 05 Duration COBRA Continuation Coverage can be extended for
a) 18 months if coverage ended due to a reduction in your work hours or
termination of your employment and you or one of your covered Dependents is
not Social Security disabled within 60 days of the date you lose coverage due to
termination of employment or reduction in 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 prior
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 eligibility for medical
coverage due to your death your divorce or legal separation your entitlement to
Medicare after your termination or reduction in hours or your Dependent child
ceasing to qualify as a Dependent under the Plan
c) 29 months if you lose coverage due to a termination of employment or reduction
in hours and you or a Dependent is disabled as defined by Title II or Title XVI
of the Social Security Act within 60 days of the original qualifying event In
this case you may continue 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 Security disability, you must notify the Plan
Administrator of the disability before the end of the initial 18 months of COBRA continuation coverage
and within 60 days following the date you or a covered Dependent is determined to be disabled by the
Social Security Administration If the disabled individual should no longer be considered to be disabled
by the Social Security Administration you must notify the Plan Administrator within 30 days following
the end of the disability Coverage that has exceeded the original 18 -month continuation period will end
when the individual is no longer Social Security disabled
If more than one qualifying event occurs no more than 36 months total of COBRA continuation coverage
will be available The COBRA beneficiary must experience the second qualifying event during the first
18 months of COBRA continuation and must provide notice to the Plan Administrator within 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 in hours unless the new group coverage is
limited due to a pre-existing condition exclusion this Plan will be primary for the
pre existing condition and secondary for all other eligible health care expenses
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provided contributions for COBRA coverage continue to be paid Coverage may
only continue for the remainder of the original COBRA period,
b) fails to make required contributions when due
c) first becomes entitled to Medicare benefits after the initial COBRA qualifying
event, or
d) is extending the 18 month coverage period because of disability and is no longer
disabled as defined by the Social Security Act
9 05 Continuation Coverage During Leaves of Absence
9 05 01
Family and Medical Leaves of Absence (FMLA) Under FMLA you may be entitled
to up to a total of 12 weeks of unpaid job protected leave during each calendar year
for the following
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 serious 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 in effect on the date your FMLA leave begins 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 terminating 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 intent either to terminate your employment or to
extend the period of leave, your 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 in status event or a special enrollment event
under The Health Insurance Portability and Accountability Act of 1996 (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 (including coverage for enrolled
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 in the Plan
Whether or not you continue coverage during military service you may reinstate coverage under the Plan
option you elected on your return to employment under USERRA The reinstatement will be without any
waiting period otherwise required under the Plan except to the extent that you had not fully completed
any required waiting period prior to the start of the military service
9 06 Conversion After Continuation Coverage See Section 8 04
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9 07 Extension of Benefits In the event this Contract is terminated for any reason except nonpayment
of premium or as set forth in 9 07 03 such termination shall be without prejudice to any
continuous losses to a Subscriber or Member which commenced while this Contract was in force
but any extension of benefits beyond the date of termination shall be predicated upon the
continuous Total Disability as defined in Section 3 45 of the Subscriber or Member and shall be
limited to payment for the treatment of a specific accident or illness incurred while the Subscriber
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 following events
a) The expiration of 12 months
b) Such time as the Member is no longer totally disabled,
c) A succeeding carrier elects to provide replacement coverage without limitation 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 carrier a
reasonable extension of this Contract's benefits will be provided to cover maternity
expenses for a covered pregnancy that commenced while the policy was in effect
The extension shall be for the period 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 Avmed of this Contract is based upon one or more of the following
reasons
a) Fraud or intentional misrepresentation in applying for any benefits under this
Contract
b) Disenrollment for cause
c) The Subscriber has left the geographic Service Area of AvMed with the intent to
relocate or establish a new residence outside AvMed's Service Area
X SCHEDULE OF BASIC BENEFITS
AvMed is committed to arranging for comprehensive prepaid health care services rendered to its
Subscribers through AvMed'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) Florida Statutes concerning the proper course of treatment of a Subscriber shall not be
subject to modification by AvMed or its Board of Directors Officers or Administrators However this
subsection is not intended to and shall not restrict any Utilization Management Program established by
AvMed
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 the Schedule of
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Benefits, which by reference is incorporated herein, are covered by AvMed It is the Member's
responsibility when seeking benefits under this Contract to identify himself as a Member of AvMed 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 advance authorization from
AvMed, or when the service is beyond the scope of practice authorized for that provider under State law
are not covered unless such services otherwise have been expressly authorized under the terms of this
Contract or when required to treat an Emergency Medical Condition Except for Emergency Medical
Services and Care, all services must be received from Participating Providers If a Member does not
follow the access rules, he risks having the 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 The following services require authorization from AvMed's Benefit
Coordination Department
1 Inpatient admissions
2 All Home Health Care Services
3 Complex diagnostic procedures performed in an outpatient Hospital Hospital affiliated
diagnostic treatment facility, or free-standing diagnostic treatment facility
4 Surgical procedures or services performed in an outpatient Hospital Hospital -affiliated
ambulatory surgery center or free standing ambulatory surgery center
5 All drugs administered in an outpatient Hospital or infusion therapy setting
6 Select drugs administered in a physician s office
7 Care rendered by Non participating Providers (except for Emergency Medical Services and
Care)
8 Transplant services
9 Dialysis services
Also Members must understand that services will not be covered if they are not in AvMed Health Plans'
opinion, Medically Necessary Any and all decisions made by AvMed in administering the provisions of
this Contract including 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 AvMed 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 limitation, the most appropriate 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 AvMed 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 participating or non participating does not in itself
make such service Medically Necessary Subscribing Group and Member acknowledge that it is possible
that a Member and his physician may determine that such services or supplies are appropriate even
though such services or supplies are not covered and will not be arranged or paid for by AvMed
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 BENEFITS
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 list of Participating Providers which may
change from time to time, will be provided to all Subscribing Groups The list of Participating
Providers may also be accessed from the AvMed website at v NAAN. AvMed org Notwithstanding
the printed booklet, the names and addresses of Participating Providers on file with AvMed at any
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given time shall constitute the official and controlling list of Participating Providers Pursuant to
Florida Statute there is a link available on the AvMed website to view the performance outcome
and financial data that is published by the Florida Agency for Health Care Administration
10 02 Within 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 section entitled Schedule of Basic Benefits are available only
from Participating Providers within the Service Area and except for Emergency Medical
Services and Care as provided in Section 10 12 AvMed shall have no liability or obligation
whatsoever on account of services or benefits sought or received by any Member from any Non-
participating Provider or other person, institution or organization, unless prior arrangements have
been made for the Member and confirmed by written referral or authorization from AvMed
10 03 Each Member shall select one Primary Care Physician upon enrollment If you do not select a
Primary Care Physician upon enrollment, AvMed will assign one for you You must notify and
receive approval from AvMed prior to changing your Primary Care Physician Such change will
become effective on the first day of the month after you notify AvMed You cannot change your
Primary Care Physician selection more than once per month The services of Specialty Health
Care Physicians are covered only when you are referred by your Primary Care Physician and as
approved by AvMed Health Professionals may from time to time cease their affiliation with
AvMed In such cases you will be required to receive services from another participating Health
Professional
10 04 Any Member requiring medical Hospital or ambulance services for emergencies (as described in
Sections 3 14 and 3 15) either while temporarily outside the Service Area, or within the Service
Area but before they can reach a Participating Provider may receive the emergency benefits as
specified in Section 10 12
10 05 Hospital Care Inpatient All Hospital inpatient services received at Participating Hospitals for
non mental illness or injury are provided when prescribed by Participating Physicians and pre
authorized by AvMed Inpatient services include semi private room and board birthing rooms
newborn nursery care nursing care meals and special diets when Medically Necessary use of
operating rooms and related facilities the 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 inpatient admission following Emergency
Medical Services and Care
Pre authorization from AvMed 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, including surgical
procedures anesthesia consultation and treatment by Specialty Health Care Physicians
laboratory and diagnostic imaging services and physical therapy (See Section 10 08) are
provided while the Member is admitted to a Participating Hospital as a registered bed patient
When available and requested by the Member AvMed covers the services of a certified nurse
anesthetist licensed under Chapter 464 Florida Statutes
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10 07 Physician Care Outpatient
10 07 01 Diagnosis and Treatment All Medical Services rendered by Participating Physicians
and other Health Professionals, as requested or directed by the Primary Care
Physician 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, Florida Statutes or by ophthalmologists licensed pursuant
to Chapter 458 or 459 Florida Statutes) and consultation and treatment by Specialty
Health Care Physicians Also included are non -reusable materials and surgical
supplies These services and materials are subject to the Limitations outlined in Part
XI (Limitations of Basic Benefits) See Part XII for Exclusions
10 07 02 Preventive and Health Maintenance Services The services of the Member's Primary
Care Physician for illness prevention and health maintenance, including child health
supervision services and immunizations provided in accordance with prevailing
medical standards consistent with the Recommendations for Preventive Pediatric
Health Care of the American Academy of Pediatrics and/or the Advisory Committee
on Immunization Practices sterilization (See Schedule of Benefits) periodic health
assessment physical examinations, and voluntary family planning services are also
covered These services are subject to Limitations as outlined in 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
crisis intervention These services are limited to a total of 20 outpatient visits per
Contract Year Referral for outpatient mental health services must be arranged by
the Member's Participating Physician and each visit requires a Co payment (See
Schedule of Benefits)
10 08 Physical, Occupational or Speech Therapy Short-term physical, occupational or speech therapy
provided in an outpatient or home care setting is covered for acute conditions including
exacerbation of previously treated conditions for which therapy applied for a consecutive two
month period can be expected to result in significant improvement Coverage of outpatient short-
term and rehabilitative services is limited as outlined on the Schedule of Benefits 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 following conditions acute
myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery
bypass graft (CABG), repair or replacement of heart valves or heart transplant Coverage is
limited to a maximum of 18 visits per calendar year See Schedule of Benefits for detailed
information regarding Co -payments and Limitations
10 10 Obstetrical and Gynecological Care Obstetrical care benefits as specified herein are covered and
include 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 in a Hospital will be that
determined to be Medically Necessary in compliance with Florida law and in accordance with the
Newborns and Mothers' Health Protection Act, as follows 1) hospital stays of at least 48 hours
following a normal vaginal delivery or at least 96 hours following a cesarean section 2) the
Attending Physician does not need to obtain authorization from AvMed to prescribe a Hospital
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stay of this length, and 3) AvMed will cover an extended stay if Medically Necessary however
your physician or your Hospital must precertify the extended stay and (4) shorter Hospital stays
are permitted if the attending health care provider in 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
in 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
prior referral from the Primary 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 Subscriber or the newborn adopted child of the Subscriber (as described in Subsection
4 02 02 (i)) from the moment of birth, including the Medically Necessary care or treatment of
medically diagnosed congenital defects birth abnormalities or prematurity, and transportation
costs to the nearest facility appropriately staffed and equipped to treat the newborn's condition,
when such transportation is Medically Necessary Circumcisions are provided for up to one year
from date of birth
10 12 Emergency Services All necessary physician and Hospital Services will be covered by AvMed
for Emergency Medical Services and Care (See Part III Sections 3 14 and 3 15) In the event
that Hospital inpatient services are provided following Emergency Medical Services and Care
AvMed should be notified within 24 hours or as soon as the Member is lucid and able to notify
AvMed of the inpatient admission AvMed will pay the usual, customary and reasonable charges
to a Non participating Provider 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 90 days after the emergency or as soon as reasonably possible but not later than one year
unless the Claimant was legally incapacitated
10 13 Urgent Care Services All necessary and covered services received in Urgent Care or Immediate
Care Centers or rendered in your Primary Care Physician s office after-hours for conditions as
described in Section 3 47 will be covered by AvMed See Schedule of Benefits for details In
addition, any Member requests for reimbursement (of payment made by the Member for services
rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but
not later than one year unless the Claimant was legally incapacitated
10 14 Ambulance Services as follows (i) local professional air/ground ambulance transport for
emergency services to the nearest emergency department appropriately staffed and equipped to
treat a medical condition (ii) ground transportation to an alternative level of care when associated
with an approved Hospital confinement, and (in) ground transportation to a Member s home will
be covered when associated with an approved hospitalization or other confinement and the
Member's condition requires the skill of medically trained personnel Transportation is not
covered when the skill of medically trained personnel is not required and the Member can be
safely transferred (or transported) by other means Air ambulance transportation is covered only
when the point of pick up is inaccessible by land or when distance or other obstacles are involved
in transporting the Member to the nearest emergency department equipped to adequately treat the
medical condition See Part XII for Exclusions
10 15 Other Health Care Facihty(ies) All routine 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 20 days per calendar year when a Member is admitted to such a
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facility following discharge from a Hospital, for a condition that cannot be adequately treated
with Skilled Home Health Care Services or on an ambulatory basis
10 16 Diagnostic Imaging and Laboratory All prescribed diagnostic imaging and laboratory tests and
services including 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 injury or as preventive health care services
10 17 Skilled Home Health Care Services Home Health Care Services (as defined in Section 3 20) are
covered as outlined on the Schedule of Benefits when ordered by and under the direction of the
Member's Attending Physician Physical occupational or speech therapy services provided in the
home are limited as noted in Section 10 08 Home Health Care Services that do not include a
medical diagnostic, therapeutic or rehabilitative component, or that do not require the skill of a
registered nurse, licensed practical (vocational) nurse or other healthcare personnel are not
covered Homemaker or other Custodial Care services are not covered
10 18 Hospice Services Services are available from a participating Hospice organization for a Member
whose Participating Physician has determined the Member's illness will result in a remaining life
span of six months or less
10 19 Second Medical Opinions The Member is entitled to a second medical opinion when he disputes
the appropriateness or necessity of a surgical procedure or is subject to a serious injury or illness
The Member may obtain a second medical opinion from any physician who is within AvMed's
Service Area If you chose a Participating Physician there is no prior authorization requirement
You pay only the applicable Co -payment or Deductible and Co-insurance If you choose a non-
participating physician the service is subject to prior authorization requirements You are also
responsible for 40% of the amount of usual customary and reasonable charges associated with
the consultation
Any tests that may be required to render the second medical opinion must be arranged by AvMed
and performed by Participating Providers Once a second medical opinion has been rendered,
AvMed shall review and determine AvMed s obligations under the Contract and that judgment is
controlling Any treatment the Member obtains that is not authorized by AvMed shall be at the
Member's expense
AvMed may limit second medical opinions in connection with a particular diagnosis or treatment
to three per Contract Year, if AvMed deems additional opinions to be an unreasonable over
utilization by the Member
10 20 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 primarily and customarily used to serve a medical purpose,
c) Generally is not useful to a person in the absence of illness or injury, and
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d) Is appropriate for use in a patient's home
Some examples of DME are hospital beds crutches canes walkers wheelchairs respiratory
equipment apnea monitors and insulin pumps It does not include hearing aids or corrective
lenses or the professional fee for fitting same It also does not include medical supplies and
devices such as a corset which do not require prescriptions AvMed will pay for rental of
equipment up to the purchase price Repair and/or replacements are not covered See Schedule
of Benefits for any Co payments or Limitations See Part XII for Exclusions
10 21 Orthotic Appliances Coverage for orthotic appliances is limited to custom made leg, arm back
and neck braces when related to a surgical procedure or when used in an attempt to avoid surgery
and when necessary to carry out normal activities of daily living, excluding sports activities
Coverage includes the initial purchase fitting or adjustment Replacements are covered only
when Medically Necessary due to a change in bodily configuration All other orthotic appliances
are not covered See Schedule of Benefits for any Co payments or Limitations See Part XII for
Exclusions
10 22 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 fitting, or adjustment Replacement is
covered only when Medically Necessary due to a change in bodily configuration The initial
prosthetic device following a covered mastectomy is also covered Replacement of intraocular
lenses is covered only if there is a change in prescription that cannot be accommodated by
eyeglasses All other prosthetic devices are not covered See Schedule of Benefits for any Co -
payments or Limitations See Part XII for Exclusions
10 23 Payment to Non participating Providers When in the professional judgment of AvMed's
Medical Director a Member needs covered Medical Services or Hospital Services which require
skills or facilities not available from Participating Providers and it is in the best interest of the
Member to obtain the needed care from a Non participating Provider upon authorization by the
Medical Director payment not to exceed usual customary and reasonable charges for such
covered services rendered by a Non participating Provider will be made by AvMed Charges for
non participating Hospital Services will be reimbursed in accordance with the covered benefits
the Member would be entitled to receive in a Participating Hospital
10 24 Prescription Drug Benefits Allergy serums and chemotherapy for cancer patients are covered
Coverage for insulin and other diabetic supplies is described in Section 10 27 below Other retail
prescription drugs are a covered benefit only when the Subscribing Group Contract includes
supplemental Prescription Drug Benefits
10 25 Ventilator Dependent Care With prior authorization by AvMed Ventilator Dependent Care (See
Section 3 49) is covered up to a total of 100 days lifetime maximum benefit
10 26 Major organ transplants at a facility deemed appropriate and authorized by AvMed as well as
associated immunosuppressant drugs are covered except those deemed experimental (See Section
12 15)
10 27 Diabetes Treatment includes all Medically Necessary equipment supplies and services to treat
diabetes This includes outpatient self management training 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 supplies or services are Medically
Necessary Insulin pumps are covered under Section 10 20 Diabetes outpatient self -
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management training and educational services must be provided under the direct supervision of a
certified diabetes educator or a board certified endocrinologist under contract with AvMed In
accordance with Florida Statutes, coverage of insulin pumps for the treatment of diabetes will not
apply toward or be subject to the annual DME maximum limitation
Insulin insulin syringes lancets and test strips are covered under the Subscribing Group's
supplemental Prescription Drug Benefits In the event that a Subscribing Group does not purchase
supplemental Prescription Drug Benefits, insulin, insulin syringes, lancets, and test strips are
covered subject to a $25 Co payment per item for a 30 -day supply
10 28 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
10 29 Osteoporosis Diagnosis and Treatment when Medically Necessary for high -risk individuals e g
estrogen deficient individuals individuals with vertebral abnormalities individuals on long-term
glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism and individuals
with a family history of osteoporosis
10 30 Dermatological Services AvMed will cover up to five office visits per calendar year to a
participating dermatologist for Medically Necessary covered services subject to Sections 3 28 and
3 48 No prior referral is required for these services
10 31 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 symmetrical
appearance and 3) prostheses and physical complications during all stages of mastectomy
including lymphedemas The length of stay will not be less than that determined by the
Attending Physician to be Medically Necessary in accordance with prevailing medical standards
and after consultation with the covered patient Coverage is subject to any applicable Co -
payments and will require pre -authorization of services as applicable to other surgical procedures
or hospitalizations under the Plan
10 32 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 in a Hospital or ambulatory surgical center due to a significantly complex dental
condition or a developmental disability in which patient management in 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 risk for the Member in the course of delivery of any necessary
dental treatment or surgery if not rendered in a Hospital or ambulatory surgical center Pre -
authorization by AvMed is required There is no coverage for diagnosis or treatment of dental
disease
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10 33 Coverage for cleft lip 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
10 34 Outpatient therapeutic services Covered health services for therapeutic treatments received on an
outpatient basis in your home physician s office Other Health Care Facility or Hospital
including intravenous chemotherapy or other intravenous infusion therapy and Injectable Drugs
Injectable Drugs that are approved for self injection are only a covered benefit when included in
the supplemental Prescription Drug Benefits (See Section 12 10)
10 35 Ostomy supplies and urinary catheter bags are covered when Medically Necessary Provisions of
ostomy and urostomy supplies are limited to a one month supply every 30 days Items which are
not medical supplies or which could be used by the Member or a family member for purposes
other than ostomy care are not covered
10 36 Wound care supplies as part of an approved treatment plan, when one of the following criteria
is met
(i) treatment of a wound caused by or treated by a surgical procedure
(u) treatment of a wound that required debridement or
(iii) participation in AvMed's wound care program
Provision of wound care supplies is limited to a one month supply every 30 days
XI LIMITATIONS OF BASIC BENEFITS
The rights of Members and obligations of Participating Providers hereunder are subject to the
following Limitations
11 01 In the event of any major disaster Participating Providers shall render Hospital and Medical
Services provided under this Contract insofar as practical according to their best judgment
within the limitations of such facilities and personnel as are then available but AvMed and
Participating Providers shall have no liability or obligation for delay or failure to provide or
arrange for such services due to lack of available facilities or personnel if such lack is the result of
any major disaster
11 02 In the event of circumstances not reasonably within the control of AvMed such as complete or
partial destruction of facilities an act of God war riot civil insurrection disability of a
significant part of Hospital or participating medical personnel or similar causes if the rendition of
Medical Services and Hospital Services provided under this Contract is delayed or rendered
impractical neither AvMed Participating Providers nor any physician shall have any liability or
obligation on account of such delay or failure to provide services however AvMed 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 that in the judgment of the Member's Primary
Care Physician, are essential to the maintenance of the Member's good health
11 04 A Member shall select one Primary Care Physician upon enrollment If you do not select a
Primary Care Physician upon enrollment a Primary Care Physician will be assigned to you by
AvMed You may obtain assistance in making a selection by contacting AvMed
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11 05 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 rehabilitation services are not covered
11 06 Visits to licensed dietitians/nutritionists for treatment of diabetes, renal disease or obesity control
shall be limited to three outpatient visits per calendar year and each visit requires a Co -payment
(See Schedule of Benefits and also Section 12 21)
11 07 Spinal manipulations will be covered only when Medically Necessary and prescribed by a
Participating Physician or by self -referral to a Participating Physician
11 08 The total benefit for Ventilator Dependent Care is limited to 100 calendar days lifetime
maximum
11 09 Inpatient Hospital care for a medical "emergency," in -area or out of -area, will only be covered
when authorized by AvMed after the Member or the Hospital notifies AvMed within 24 hours of
admission or as soon as the Member is lucid and able to notify AvMed of the admission
following Emergency Medical Services and Care
11 10 Other Health Care Facility(ies) All routine inpatient 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 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 explained in Sections 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
functional disorder as a result of a disease, injury, or congenital defect or initial implanted
prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast
11 13 Hyperbaric oxygen treatments are limited to 40 treatments per condition as appropriate pursuant to
the Centers for Medicare and Medicaid Services (CMS) guidelines subject to applicable Co -
payments as listed for physical, speech and occupational therapies
XII EXCLUSIONS FROM BASIC BENEFITS
Medical Services and benefits for the following classifications and conditions are not covered and are
excluded from the Schedule of Basic Benefits provided under this Contract
12 01 Treatment of a condition resulting from
a) Participation in a riot or rebellion
b) Engagement in an illegal occupation,
c) Commission or attempted commission of an assault, commission or attempted commission
of a crime punishable as a felony
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12 02 Cosmetic, surgical or non -surgical procedures which are undertaken primarily to improve or
otherwise modify the Member's external appearance Also excluded are surgical excision or
reformation of any sagging skin of any part of the body including but not limited to the eyelids
face neck abdomen arms legs, or buttocks any services performed in connection with the
enlargement, reduction, implantation or change in appearance of a portion of the body including
but not limited to the face lips, jaw chin nose ears breasts or genitals (including 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 skin electrolysis depilation, removal of
tattooing or any other surgical or non surgical procedures which are primarily for cosmetic
purposes or to create body symmetry Additionally, all medical complications as a result of
cosmetic surgical or non surgical procedures are excluded
12 03 Medical care or surgery not authorized by a Participating Provider except for Emergency
Medical Services and Care or not within the benefits covered by AvMed
12 04 Dental Care, as defined in 3 11, for any condition except
a) When such services are for the treatment of trauma related fractures of the jaw or
facial bones or for the treatment of tumors,
b) Reconstructive jaw surgery for the treatment of deformities that are present and
apparent at birth or
c) 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 injury
12 07 Except as provided in Sections 10 35 and 10 36, medical supplies including, but not limited to
pre fabricated splints Thromboemboletic/Support hose and all other bandages
12 08 Home monitoring 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
intraocular 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 (including drugs and devices) hypodermic
needles and syringes and Self Administered Injectable Drugs except insulin and insulin syringes
for the treatment of diabetes as outlined in Section 10 27
12 11 Travel expenses including expenses for ambulance services to and from a physician or Hospital
except in accordance with Section 10 14
12 12 Treatment for chronic alcoholism and chronic drug addiction except those services offered as a
basic health service (See Section 11 05)
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12 13 Treatment for armed forces service connected medical care (for both sickness and injury)
12 14 Custodial Care (as defined in Part III, Section 3 10)
12 15 Experimental and/or investigational procedures, except for bone marrow transplants as 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 FDA has not granted the approval for general use
b) There are insufficient outcomes data available from controlled clinical trials published in
peer reviewed literature to substantiate its safety and effectiveness for the disease or injury
involved
c) There is no consensus among practicing physicians that the drug, treatment, therapy,
procedure or device is safe or effective for the treatment in question or such drug, treatment
therapy procedure or device is not the standard treatment therapy procedure or device
utilized by practicing physicians in treating other patients with the same or a similar
condition, or
d) Such drug, treatment procedure or device is the subject of an ongoing Phase I or Phase II
clinical investigation or experimental or research arm of a Phase III clinical investigation or
under study to determine maximum tolerated dosages toxicity safety efficacy or efficacy
as compared with the standard means for treatment or diagnosis of the condition in 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 injury This Exclusion includes but is not
limited to wigs (including partial hair pieces, weaves and toupees) personal care kits guest
meals and accommodations, maid services televisions/radios telephone charges, photographs
complimentary meals birth announcements, take home supplies travel expenses (other than
Medically Necessary ambulance services that are provided for in Section 10 14) air conditioners
humidifiers dehumidifiers, and air purifiers or filters
12 17 Physical examinations or tests such as premarital blood tests or tests for continuing employment
education licensing, or insurance or that are otherwise required by a third party
12 18 Eye care including
a) Eye examinations for Members 18 years of age or older for the purpose of determining the
need for sight correction (such as eye glasses or contact lenses)
b) Training or orthoptics including eye exercises or
c) Radial keratotomy refractory keratoplasty Lasik surgery or any other corneal surgical
procedure to correct refractive error
12 19 Hearing examinations for Members 18 years of age or older for the purpose of determining the
need for hearing correction
12 20 Cosmetics, dietary supplements, nutritional formulae, health or beauty aids
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12 21 Gastric stapling gastric bypass, gastric banding gastric bubbles, and other procedures for the
treatment of obesity or morbid obesity as well as any related evaluations or diagnostic tests
Ongoing 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 supplies including infertility testing treatment of infertility
diagnostic procedures and artificial insemination to determine or correct the cause or reason for
infertility or inability to achieve conception This includes artificial insemination in vitro
fertilization ovum or embryo placement or transfer gamete intra-fallopian tube transfer or
cryogenic 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 Florida Statutes Drugs for the treatment of infertility
are not covered
12 25 Reversal of sterilization procedures
12 26 Immunizations and medications for the purpose of foreign travel or employment
12 27 Acupuncture biofeedback hypnotherapy massage therapy sleep therapy sex therapy
behavioral training, cognitive therapy and vocational rehabilitation
12 28 Foot supports are not covered These include orthopedic or specialty shoes, shoe build ups, shoe
orthotics shoe braces and shoe supports Also excluded is routine foot care, including trimming
of corns calluses and nails
12 29 The Medical Services and Hospital Services for a donor or prospective donor who is an AvMed
Member when the recipient of an organ transplant is not an AvMed Member Coverage is
provided for costs associated with the bone marrow donor -patients to the same extent as the
insured 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 testing and treatment related to mental retardation or deficiency learning disabilities
behavioral problems developmental delays Autism Spectrum Disorder or Attention Deficit
Hyperactivity Disorder (ADHD) Expenses for remedial or special education counseling or
therapy including evaluation and treatment of the above -listed conditions or behavioral training
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 treatment or service from a Non -participating Provider except in the case of an emergency
or when specifically pre authorized by AvMed (See Sections 3 14 and 3 15)
12 34 Speech therapy for delayed or abnormal speech pathology
12 35 Alcohol or substance abuse rehabilitation, vocational rehabilitation, pulmonary rehabilitation
long term rehabilitation, or any other rehabilitation program
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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
amendment to the Subscribing Group Contract
12 38 Hospital Exclusion If a Member elects to receive Hospital care from a non participating
Attending Physician or a non participating Hospital, then coverage is excluded for the entire
episode of care except when the admission was due to an emergency or with the prior written
authorization of AvMed
12 39 Ventilator Dependent Care, except as provided in Part X (Schedule of Basic Benefits) for 100
days lifetime maximum benefit
12 40 Private duty nursing services
12 41 Any sickness or injury 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 into a settlement giving up rights to recover past or future
medical benefits under a Workers' Compensation law AvMed 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 AvMed shall not cover the balance of any costs
remaining after the program has paid
12 42 Complications of any non -covered service including the evaluation or treatment of any condition
that arises 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, including the autopsy
12 45 Exercise programs gym memberships or exercise equipment of any kind including, but not
limited to exercise bicycles, treadmills, stairmasters rowing 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 skin 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 to 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
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accident benefits to a Member, including but not limited to Medicare Worker's Compensation
Public Health Service Champus Maritime Health Benefits or similar state programs as
permitted by contract policy or law AvMed coverage will be primary to Medicaid benefits
13 02 If any covered person is eligible for services or benefits under two or more plans as set forth in
Section 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 combined The
Member shall execute and deliver such instruments and papers as may be required and do
whatever else is necessary to secure such rights to AvMed Failure to do so will result in
nonpayment of claims Requested information should be provided to AvMed within 30 days of
request or Member will be responsible for payment of claim Information received after one year
from date of service will not be considered
13 03 The standards governing the coordination of benefits are the following, pursuant to the provisions
of Section 627 4235, Florida Statutes
13 03 01 The benefits of a policy or plan which covers the person as an employee, member or
subscriber, other than as a dependent are determined before those of the policy or
plan which covers the person as a dependent
13 03 02 Except as stated in 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 excluding year of
birth falls earlier in a year are determined before the benefits of the policy or
plan of the parent whose birthday excluding year of birth falls later in the year
but
b) If both parents have the same birthday the benefits of the policy or plan which
covered the parent for a longer period of time are determined before those of the
policy or plan which covered the parent for a shorter period of time
However if a policy or plan subject to the rule based on the birthday of the parents as
stated above coordinates with an out of -state policy or plan which contains
provisions under which the benefits of a policy or plan which covers a person as a
dependent of a male are determined before those of a policy or plan which covers the
person as a dependent of a female and if as a result the policies or plans do not agree
on the order of benefits the provisions of the other policy or plan shall determine the
order of benefits
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 having custody of the child
However if the specific terms of a court order state that one of the parents is
responsible for the health care expenses of the child and if the entity obliged to pay or
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provide the benefits of the policy or plan of that parent has actual knowledge of those
terms the benefits of that policy or plan are determined first This does not apply
with respect to any claim determination period or plan or policy year during which
any benefits are actually paid or provided before that entity has that actual
knowledge
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 policy or plan which covered an
employee member or subscriber for a longer period of time are determined before
those of the policy or plan which covered that person for the shorter period of time
13 03 06
Coordination of benefits shall not be permitted against an indemnity type policy an
excess insurance policy as defined in Section 627 635 Florida Statutes a policy with
coverage limited to specified illnesses or accidents or a Medicare supplement policy
However if the person is also a Medicare beneficiary, and if the rule established
under the Social Security Act of 1965, as amended makes Medicare secondary to the
plan covering the person as a dependent of an active employee the order of benefit
determination is
a) First benefits of a plan covering a person as an employee member or subscriber
b) Second, benefits of a plan of an active worker covering a person as a dependent
c) Third Medicare benefits
13 03 07 If an individual is covered under a COBRA continuation 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
Health Insurance plan, the following order of benefits applies
a) First, the plan covering the person as an employee, or as the employee's
dependent
b) Second the coverage purchased under the plan covering the person as a former
employee, or as the former employee's dependent provided according to the
provisions of COBRA
13 04 For the purpose of determining the applicability and implementing the terms of the Coordination
of Benefits provision of this Contract AvMed may, without the consent of or notice to any
person release to or obtain from any other insurance company, organizations or person any
information, with respect to any Subscriber or applicant for subscription, which AvMed deems to
be necessary for such purposes
13 05 Whenever payments which should have been made under this Plan in accordance with this
provision have been made under any other plans, AvMed shall have the right, exercisable alone
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and in its sole discretion to pay over to any organizations making such other payments any
amounts AvMed shall determine to be warranted in order to satisfy the intent 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 AvMed is secondary to other coverage and the treatment is
covered under the other coverage
XIV REIMBURSEMENT
In the event that AvMed provides medical benefits or payments to a Member who suffers injury disease
or illness by virtue of a negligent act or omission by a third party, AvMed is entitled to reimbursement
from the Subscriber in accordance with Section 768 76(4) Florida Statutes If the Subscriber recovers all
or part of such medical benefits, payments or expenses from the third party AvMed may take any action
it deems necessary to protect its rights to recover the amount of any payments made by AvMed including
the right to bring suit in Member's name if the Member chooses not to file suit In that case Member shall
provide a written assignment to AvMed of Member s rights to all claims demands, and rights to recovery
that Member may have against the third party
Should Member file suit Member is required to notify AvMed as required by Section 768 76 Florida
Statutes In any suit Member shall bring a separate claim for reimbursement of amounts paid by AvMed
and shall not enter into any settlement that does not provide for reimbursement of the amounts paid by
AvMed Member shall execute and deliver any and all instruments and papers as may be required by
AvMed and do whatever else is necessary to secure and protect the recovery rights of AvMed In the
event of any recovery Member shall hold such proceeds in trust for the benefit of AvMed and pay them
to AvMed upon demand if the proceeds have been paid directly to the Member In the event of a trial
Member shall present evidence of the amounts paid by AvMed and shall seek a separate special verdict
for reimbursement of such amounts in favor of AvMed At any time AvMed shall be allowed to
intervene in any suit brought by Member against any third party and if Member opposes such
intervention Member shall pay all costs and attorney fees incurred by AvMed in the process of seeking
the order of the court for such intervention over Member s objections
XV DISCLAIMER OF LIABILITY
15 01 Neither Subscribing Group nor its agents servants or employees nor any Member is the agent or
representative of AvMed and none of them shall be liable for any acts or omissions of AvMed
its agents or employees or of a Participating Hospital or a Participating Physician or any other
person or organization with which AvMed has made or hereafter shall make arrangements for the
performance of services under this Contract
15 02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to AvMed or
Participating Providers except as specifically set forth herein provided all procedures set forth
herein are followed
15 03 Neither AvMed nor its agents servants or employees nor any Member is the agent or
representative of the Subscribing Group and none of them shall be liable for any acts or
omissions of Subscribing Group, its agents or employees or any other person representing or
acting on behalf of Subscribing Group
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15 04 AvMed does not directly employ any practicing physicians nor any Hospital personnel or
physicians These health care providers are independent contractors and are not the agents or
employees of AvMed AvMed shall be deemed not to be a health care provider with respect to
any services performed or rendered by any such independent contractors Participating Providers
maintain the physician/patient relationship with Members and are solely responsible for all
Medical Services which Participating Providers render to Members Therefore AvMed shall not
be liable for any negligent act or omission committed by any independent practicing physicians
nurses, or medical personnel, nor any Hospital or health care facility its personnel other health
care professionals or any of their employees or agents who may from time to time provide
Medical Services to a Member of AvMed Furthermore AvMed shall not be vicariously liable
for any negligent act or omission of any of these independent health care professionals who treat
a Member of AvMed
15 05 Certain Members may for personal reasons refuse to accept procedures or treatment
recommended by Participating Physicians Participating Physicians may regard such refusal to
accept their recommendations as incompatible with the continuance of the physician/patient
relationship and as obstructing the provision of proper medical care If a Member refuses to
accept the medical treatment or procedure recommended by the Participating Physician and if in
the judgment of the Participating 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 AvMed may
terminate the Member's coverage under this Contract as set forth in 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 AvMed AvMed shall notify the Claimant of AvMed's benefit determination
(whether adverse or not) as soon as possible taking into account the medical
exigencies but not later than 72 hours after AvMed receives, either orally or in
writing 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 Plan If such information is not provided AvMed shall notify the Claimant
as soon as possible but not later than 24 hours after AvMed receives the Claim, of the
specific information necessary to complete the Claim The Claimant shall be afforded
a reasonable amount of time taking into account the circumstances but not less than
48 hours to provide the specified information AvMed shall notify the Claimant of
the benefit determination as soon as possible but in no case later than 48 hours after
the earlier of
1) AvMed s receipt of the specified information or
2) The end of the period afforded the Claimant to provide the specified additional
information
If the Claimant fails to supply the requested information within the 48 -hour period the Claim
shall be denied AvMed may notify the Claimant of its benefit determination orally or in writing
If the notification is provided orally, a written or electronic notification, meeting the requirements
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of Section 16 05, shall be provided to the Claimant no later than three 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 in accordance with Section 16 07 of AvMed s
benefit determination on review as soon as possible taking into account the medical
exigencies but not later than 72 hours after AvMed 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, Florida 32602 0823
Telephone 1 800 882-8633
Fax (352) 337 8612
AvMed Member Services — South
P O Box 569008
Miami, Florida 33156 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 writing
within 365 days of receipt of the final decision letter If you appeal AvMed s decision your
grievance will be reviewed by the Subscriber Assistance Program You also have the right to
contact the AHCA or DFS at any time to inform them of an unresolved grievance
The Subscriber Assistance Program will not hear a grievance if you have not completed the entire
AvMed grievance process nor if you have instituted an action pending in State or Federal court
If you need further assistance you may contact
Subscriber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive Mail Stop 26
Tallahassee Florida 32308
Telephone 1 888 419 3456 or 850 921-5458
The Florida Department of Financial Services
200 East Gaines Street
Tallahassee Florida 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
AvMed AvMed shall notify the Claimant of the benefit determination (whether
adverse or not) within a reasonable period of time appropriate to the medical
circumstances but not later than 15 days after AvMed receives the Pre -Service Claim
AvMed may extend this period one time for up to 15 days, provided that AvMed
determines that such an extension is necessary due to matters beyond AvMed s control
and notifies the Claimant before the expiration of the initial 15 day period of the
circumstances requiring the extension of time and the date by which AvMed expects to
render a decision If such an extension is necessary because the Claimant failed to
submit the information necessary to decide the Claim the notice of extension shall
specifically describe the required information and the Claimant shall be afforded at
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least 45 days from receipt of the notice within which to provide the specified
information In the case of a failure by a Claimant to follow AvMed'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 days
following such failure AvMed's period 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 information within 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 receiving the Adverse Benefit Determination
AvMed shall notify the Claimant, in accordance with Section 16 07 of it s
determination on review within a reasonable period of time Such notification shall be
provided not later than 30 days after AvMed 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, Florida 32602-0823
Telephone 1 800 882 8633
Fax (352) 337 8612
AvMed Member Services — South
P O Box 569008
Miami, Florida 33156-9906
Telephone 1 800-882 8633
Fax (305) 671-4736
If you are not satisfied with AvMed s final decision, you may contact AHCA or DFS in writing
within 365 days of receipt of the final decision letter If you appeal AvMed s decision your
grievance will be reviewed by the Subscriber Assistance Program You also have the right to
contact AHCA or DFS at any time to inform them of an unresolved grievance
The Subscriber Assistance Program will not hear a grievance if you have not completed the entire
AvMed grievance process nor if you have instituted an action pending in State or Federal court
it you need further assistance you may contact
Subscriber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1 888 419 3456 or 850 921 5458
The Florida Department of Financial Services
200 East Gaines Street
Tallahassee Florida 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 AvMed AvMed shall notify the Claimant in accordance with Section 16 05 of
AvMed s Adverse Benefit Determination within a reasonable period of time but not
later than 30 days after AvMed receives the Post Service Claim AvMed may extend
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AV G100 2005
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this period one time for up to 15 days provided that AvMed determines that such an
extension is necessary due to matters beyond AvMed'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 AvMed expects to render a
decision If such an extension is necessary because the Claimant failed to submit the
information necessary to decide the Post Service Claim the notice of extension shall
specifically describe the required information and the Claimant shall be afforded at
least 45 days from receipt of the notice within which to provide the specified
information AvMed's period 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 information within the 45 -day period 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 receiving the Adverse Benefit Determination
AvMed shall notify the Claimant in accordance with Section 16 07 of AvMed s
determination on review within a reasonable period of time Such notification shall be
provided not later than 60 days after AvMed 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 Florida 32602 0823
Telephone 1 800 882 8633
Fax (352) 337 8612
AvMed Member Services — South
P O Box 569008
Miami Florida 33156 9906
Telephone 1 800-882 8633
Fax (305) 671 4736
If you are not satisfied with AvMed's final decision you may contact AHCA or DFS in
writing within 365 days of receipt of the final decision letter If you appeal AvMed's
decision your grievance will be reviewed by the Subscriber Assistance Program
You also have the right to contact the AHCA or DFS at any time to inform them of an
unresolved grievance
The Statewide Provider and Subscriber Assistance Program will not hear a grievance if you
have not completed the entire AvMed grievance process nor if you have instituted an action
pending in State or Federal court
If you need further assistance, you may contact
Subscriber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee Florida 32308
Telephone 1 888 419 3456 or 850-921 5458
The Florida Department of Insurance
200 East Gaines Street
Tallahassee Florida 32399
Telephone 1 800 342 2762
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16 04 Concurrent Care Claims
16 04 01 Any reduction or termination by AvMed of Concurrent Care (other than by Plan
amendment or termination) before the end of an approved period of time or number of
treatments shall constitute an Adverse Benefit Determination AvMed shall notify the
Claimant in accordance with Section 16 05 of the Adverse Benefit Determination at a
time sufficiently in advance of the reduction or termination to allow the Claimant to
appeal and obtain a determination on review of the Adverse Benefit Determination
before the benefit is reduced or terminated
16 04 02 Any request by a Claimant to extend the course of treatment beyond the period of time
or number of treatments that relates to an Urgent Care Claim shall be decided as soon
as possible taking into account the medical exigencies, and AvMed shall notify the
Claimant of the benefit determination, whether adverse or not within 24 hours after
AvMed receives the Claim, provided that any such Claim is made to AvMed at least 24
hours before the expiration of the prescribed period of time or number of treatments
Notification and appeal of any Adverse Benefit Determination concerning a request to
extend the course of treatment whether involving an Urgent Care Claim or not shall be
made in accordance with the remainder of Part XVI
16 05 Manner and Content of Initial Claims Determination Notification AvMed shall provide a Claimant
with written or electronic notification of any Adverse Benefit Determination The notification shall
set forth in a manner calculated to be understood by the Claimant, the following
a) The specific reasons for the Adverse Benefit Determination
b) Reference to the specific Plan provisions on which the determination is based
c) A description of any additional material or information necessary for the Claimant to
perfect the Claim and an explanation of why such material or information is necessary
d) A description of AvMed's review procedures and the time limits applicable to such
procedures, including, when applicable a statement of the Claimant s right to bring a
civil action under Section 502(a) of the Employee Retirement Income Security Act of
1974 as amended (ERISA) following an Adverse Benefit Determination on final
review
e) If an internal rule guideline protocol or other similar criterion was relied upon in
making the Adverse Benefit Determination either the specific rule guideline, protocol
or other similar criterion or a statement that such rule guideline protocol or other
similar criterion was relied upon in 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
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 Plan
to the Claimant s medical circumstances or a statement that such explanation shall be
provided free of charge upon request
g) In the case of an Adverse Benefit Determination involving an Urgent Care Claim a
description of the expedited review process applicable to such Claim
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16 06 Review Procedure Upon Appeal AvMed s appeal procedures shall include the following
substantive procedures and safeguards
a) Claimant may submit written comments documents records and other information relating
to the Claim
b) Upon request and free of charge, the Claimant shall have reasonable access to and copies of
any Relevant Document
c) The appeal shall take into account all comments documents records and other information
the Claimant submitted relating to the Claim without regard to whether such information was
submitted or considered in the initial Adverse Benefit Determination
d) The appeal shall be conducted by an appropriate named fiduciary of AvMed who is neither
the individual who made the initial Adverse Benefit Determination nor the subordinate of
such individual Such person shall not defer to the initial Adverse Benefit Determination
e) In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part
on a medical judgment including determinations with regard to whether a particular
treatment drug or other item is experimental and/or investigational or not Medically
Necessary the appropriate named fiduciary shall consult with a Health Professional who has
appropriate training and experience in the field of medicine involved in the medical
Judgment
f) The appeal shall provide for the identification of medical or vocational experts whose advice
was obtained on behalf of AvMed in connection with a Claimant s Adverse Benefit
Determination without regard to whether the advice was relied upon in making the Adverse
Benefit Determination
g) The appeal shall provide that the Health Professional engaged for purposes of a consultation
in Subsection 16 06 05 shall be an individual who is neither an individual who was consulted
in connection with the initial Adverse Benefit Determination that is the subject of the appeal,
nor the subordinate of any such individual
h) In the case of an Urgent Care Claim there shall be an expedited review process pursuant to
which
(i) request for an expedited appeal of an Adverse Benefit Determination may be
submitted orally or in writing by the Claimant and
(ii) all necessary information including AvMed's benefit determination on review
shall be transmitted between AvMed 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 written or
electronic notification of AvMed s benefit determination upon review
16 07 01 In the case of an Adverse Benefit Determination the notification shall set forth in a
manner calculated to be understood by the Claimant all of the following as
appropriate
a) The specific reasons for the Adverse Benefit Determination
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b) Reference to the specific 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 describing any voluntary appeal procedures offered by AvMed and the
Claimant's right to obtain the information about such procedures and a statement of the
Claimant s right to bring an action under ERISA Section 502(a) when applicable
e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in
making the Adverse Benefit Determination, either the specific rule, guideline protocol
or other similar criterion or a statement that such rule guideline protocol or other
similar criterion was relied upon in 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
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 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 executing this Contract, Subscribing Group and AvMed agree to make
the Medical Services and Hospital Services specified herein available to persons who are eligible
under the provisions of Part IV However the delivery of benefits and services covered in this
Contract shall be subject to the provisions Limitations, and Exclusions set forth herein and any
amendments modifications, and Contract termination provisions specified herein and by the
mutual agreement between AvMed and Subscribing Group, without the consent or concurrence of
the Members By electing or accepting Medical Services and Hospital or other benefits
hereunder all Members legally capable of contracting and the legal representatives of all
Members incapable of contracting agree to all terms conditions and provisions hereof
No changes or amendments to this Contract shall be valid unless approved by an executive officer
of AvMed and endorsed herein or attached hereto No agent has authority to change this Contract
or to waive any of its provisions
17 02 Certificate of Coverage AvMed shall provide a copy of the Certificate of Coverage for each
Subscriber
17 03 Membership Application Members or applicants for membership shall complete and submit to
AvMed such applications or other forms or statements as AvMed may reasonably request If
Member or applicant fails to provide accurate information which AvMed deems material then
upon ten days written notice AvMed may deny coverage and/or membership to such individual
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 punishable as provided by the Florida Statutes
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17 04 Identification Cards Cards issued by AvMed to Members pursuant to this Contract are for
purposes of identification only Possession of an AvMed identification card confers no right to
health services or other benefits under this Contract To be entitled to such services or benefits
the holder of the card must, in fact be a Member on whose behalf all applicable charges under
this Contract have actually been paid and accepted by AvMed
17 05 Waiver A Claim that has not been timely filed with AvMed within one year of date of service
shall be considered waived
17 06 Non -Waiver The failure of AvMed to enforce any of the provisions of this Contract or to
exercise any options herein provided or to require timely performance by any Member or
Subscribing Group of any of the provisions herein shall not be construed to be a waiver of such
provisions nor shall it affect the validity of this Contract or any part thereof or the right of AvMed
to thereafter enforce each and every such provision
17 07 Plan Administration AvMed 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 AvMed, to
AvMed Health Plans
P O Box 749
Gainesville Florida 32602 0749
(OR if from a Member to AvMed 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 AvMed
on the enrollment application or change of address notification
If to Subscribing Group To the address provided in the Group Master Application
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 Clerical errors shall neither deprive any individual Member of any benefits or
coverage provided under this Group Contract nor shall such errors act as authorization of benefits
or coverage for the Member that is not otherwise validly in force Retroactive adjustments in
coverage for clerical errors or otherwise will only be done for up to a 60 day period from the date
of notification Refunds of premiums are done for up to a 60 day period 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 Subscribing Group may if this Contract is not satisfactory for any reason,
return this Contract within three days after receipt and receive a full refund of the deposit paid if
any unless the services of AvMed were utilized during the three days If this Contract is not
returned within three 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 Subscribing Group under the terms of this Contract shall be increased
by the amount of such premium tax or surcharge
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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 Subscribing
Group and AvMed No modification (or oral representation) of this Group Contract shall be of
any force or effect unless it is in writing and signed by both parties
17 14 Rate Letter The "rate letter" is AvMed's formal notice to the Subscribing Group of the premium
rates applicable to the Subscribing 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 AvMed's reservation of the right to adjust (re rate) the premium quote to account for
changes in the group size or in the data supplied by the Subscribing Group to AvMed the
applicable employer employee contribution to the premium payment and the charge for other
optional, supplemental benefits selected by the Subscribing Group if any
17 15 Third Party Beneficiary This Contract is entered into exclusively between the Subscribing
Group and AvMed This Contract is intended only to benefit the Subscribing Group and the
Members and does not confer any rights on any other third parties
17 16 Assignment This Contract, and all rights and benefits related thereto, may not be assigned by
the Subscribing Group or the Members without written consent of AvMed
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 United States
17 18 ERISA When this Contract is purchased by the Subscribing Group to provide benefits under a
welfare plan governed by 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 Subscribing Group
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AVMED
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 2006
Group Contract
This Group Contract provides the benefits checked below
BASIC OPTION ($15 Specialist)
❑ $0 per Admission
❑ $100 per Admission
O $250 per Admission
O $250 per Day Days 1 5
BASIC OPTION ($25 Specialist)
O $0 per Admission
O $100 per Admission
O $250 per Admission
O $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
O $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
O $250 per Admission
STANDARD OPTION ($20 Specialist)
O $100 per Day Days 1 5
® $250 per Admission
Form AV STD/20 250A 05
If selected the following optional and supplemental coverage is also provided
O
El
IZI
0
El
El
IZI
Open Access
Prescription Coverage
Vision Coverage
Dental Coverage (ADP)
(All Dental Plans are administered by American Dental Plan)
Elective Termination of Pregnancy
Form
Form
Form
Form
OTHER LARGE GROUP BENEFITS
O $15/$250 PER Day Days 1 5
O $25/$500 PER Day Days 1 5
O $20/$250/10%
❑ $20/$250/20%
❑ $25/$500/20%
❑ $25/$750/20%
❑ $30/$750/20%
CORE
❑ $15/$250/25 40%
❑ $15/$500/15 30%
O $25/$250/25 40%
O $15/$1000/10 25%
❑ $15/$100/30 40%
O $25/$100/30 40%
CDHP
❑ Consumer 1A
O Consumer 1B
O Consumer 1C
as described in the amendments to this contract
AV
AV G100 RX 15/30/50/75 OC 05
AV VISION R 99
AV
Form AV G100 ETP R 97
Mental Health/Partial Hospitalization Form AV G100 MH/PH $250 per admit 04
0 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 Florida Statutes)
Durable Medical Equipment
Waiver of Co payment — Coverage for Mammograms
Other
® Domestic Partner Form AV DP 12 R 02
0 Form AV
Form AV G100 DME 2000 R 06
Form AV Mammogram 05
AVMED, INC d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
ELIGIBILITY
An employee of the Subscribing 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
El on the last date of the month in which the employee s employment is terminated
❑ on the date the Group Contract is terminated
El other
AGREEMENT
This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital
services and the monthly prepayment subscription 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 period of twelve (12) months from
the effective date of May 1 2006 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 governed by Chapter 641 Florida Statutes and other applicable State and Federal laws
The first monthly payment is due on May 1 2006 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
Subscriber Only $ 295 42
Subscriber plus Spouse $ 590 83
Subscriber plus One Dependent (No Spouse) $ 590 83
Subscriber plus Two or More Dependents $ 856 71
Subscriber plus Spouse and One or More Dependents $ 856 71
0 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 2006
Subscribing Group
Or
Name
1 l &1 e ei _.._
� teti:AIACI
)ate
0 APP 04
' (12/04)
AVMED Inc d/• _ _ VMED Health Plans
By
Signa
Evis Clavareza,
Name
Director, Client Service
�Itie
Date
AvMED
H EAI r ii P I ANS
STANDARD OPTION/20
250 ADMIT
benefit Summary
SCHEDULE OF BENEFITS
COST TO MEMBER
OUT OF POCKET MAXIMUM
Per Calendar Year
AVMED PRIMARY CARE
PHYSICIAN
AVMED SPECIALISTS'
SERVICES
Services at Participating Physicians offices include but are not
limited to
• Routine office visits / annual gynecological examination
when performed by Primary Care Physician
• Maternity outpatient visits
• Pediatric care and well child care
■ Periodic health evaluation and immunizations
• Diagnostic imaging laboratory or other diagnostic
services
■ Minor surgical procedures
• Vision and hearing examinations for children under 18
• Office visits
• Annual gynecological examination when performed by a
participating Specialty Health Care Physician
$1 500 INDIVIDUAL
$3 000 FAMILY
$10 per visit
$20 per visit
HOSPITAL
OUTPATIENT SERVICES
OUTPATIENT DIAGNOSTIC
TESTS
Inpatient care at Participating Hospitals includes
• Room and board unlimited days (semi private)
• Physicians specialists and surgeons services
• Anesthesia use of operating and recovery rooms
oxygen drugs and medication
• Intensive care unit and other special units general and
special duty nursing
■ Laboratory and diagnostic imaging
• Required special diets
• Radiation and inhalation therapies
• Outpatient surgeries including cardiac catheterizations
and angioplasty
■ Outpatient therapeutic services including
• Drug infusion therapy
• Injectable Drugs (Co payment for Injectable
Drug waived if incidental to same day drug
infusion therapy)
• CAT Scan PET Scan MRI
• Other diagnostic imaging tests
$250 per admission
100% coverage thereafter
$250 Co payment
$100 Co payment
$75 Co payment
$25 per test
$10 per test
EMERGENCY SERVICES
An emergency is the sudden and unexpected onset of a
condition requiring immediate medical or surgical care (Co
payment waived if admitted)
■ Emergency services at Participating Hospitals
■ Emergency services at non participating Hospitals
facilities and/or physicians
AvMed must be notified within 24 hours of inpatient
admission following emergency services or as soon as
reasonably possible
$75 Co payment
$100 Co payment
AV STD/20 250A 05
MP 3413 (10/05)
Benefit Summary, continued
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 Co payment
$60 Co payment
MENTAL HEALTH
■ 20 outpatient visits
$25 per visit
FAMILY PLANNING
• Voluntary family planning services
• Sterilization
$10 per visit
$100 Co payment
ALLERGY TREATMENTS
AMBULANCE
PHYSICAL, SPEECH, AND
OCCUPATIONAL THERAPIES
• Injections
• Skin testing
• Ambulance transport for emergency services
• Non emergent ambulance services are covered when the
skill of medically trained personnel is required and the
Member cannot be safely transported by other means
• Short term physical speech or occupational therapy for
acute conditions
Coverage is limited to 30 visits per calendar year for all
services combined
$10 per visit
$50 per course of testing
$100 Co payment
$10 per visit
SKILLED NURSING
FACILITIES AND
REHABILITATION CENTERS
• Up to 20 days post hospitalization care per Contract
Year when prescribed by physician and 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 valves
• Coronary artery bypass graft (CABG) or
• Heart transplant
Coverage is limited to 18 visits per Contract Year
$20 per visit
Benefits limited to $1,500
per Contract Year
HOME HEALTH CARE
• Limited to 60 skilled visits per calendar year
NO CHARGE
DURABLE MEDICAL
EQUIPMENT AND
ORTHOTIC APPLIANCES
Equipment includes
• Hospital beds
• Walkers
• Crutches
• Wheelchairs
Orthotic appliances are limited to
■ Leg arm back and neck custom made braces
$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
NO CHARGE
FOR ADDITIONAL INFORMATION, PLEASE CALL 1 800 88 AVMED (1 800 882 8633)
THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT
FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS AND LIMITATIONS PLEASE SEE YOUR AVMED GROUP
MEDICAL AND HOSPITAL SERVICE CONTRACT
AV STD/20 250A 05
MP 3413 (10/05)
Av]
HEALTH P LAN S
Prescription Drug Benefits
$15/30/50/75 CO PAYMENT with Contraceptives
DEFINITIONS
Bland drug means a Prescription Drug that is usually manufactured and sold under a name or trademark by a drug manufacturer or a drug that
is identified as a Brand drug by AvMed AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits Manger
Bvind Add!ttonn.l (hai ge means the additional charge that must be paid if you or your physician choose a Brand drug when a Generic
equivalent is available The charge is the difference between the cost of the Brand drug and the Generic drug This charge must be paid in
addition to the applicable Brand Co payment (Preferred or Non Preferred)
Generic drug means a drug that has the same active ingredient as a Brand drug or is identified as a Generic drug by AvMed s Pharmacy
Benefits Manager
Injectable Dru., is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the
following routes intramuscular injection intravenous injection intravenous infusion subcutaneous injection intrathecal injection intrarticular
injection intracavernous injection or intraocular injection Pre Authorization is required for all Injectable Drugs
P urtiLipatmg Phnr m1cs means a pharmacy (either retail mail order or specialty pharmacy) that has entered into an agreement with AvMed to
provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy
PraLlicd Diug Lost means the listing of preferred medications as determined by AvMed s Pharmacy and Therapeutics Committee based on
clinical efficacy relative safety and cost in comparison to similar medications within a therapeutic class This multi tiered list establishes
different levels of Co payment for medications within therapeutic classes As new medications become available they may be considered
excluded until they have been reviewed by AvMed s Pharmacy and Therapeutics Committee
Prescription Drui, means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according
to state and federal law
Pie Author iz ition means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed s
guidelines The prescribing physician must obtain approval from AvMed The list of Prescription Drugs requiring Pre Authorization is subject
to periodic review and modification by AvMed A copy of the list of medications requiring Pre Authorization and the applicable criteria are
available from Member Services or from the AvMed website
Self Administered lnlectlble Drug is a medication that has been approved by the FDA for self injection and is administered by subcutaneous
injection or a medication for which there are instructions to the patient for self injection in the manufacturer s prescribing information (package
insert) Pre Authorization is required for all Self Administered Injectable Drugs
HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK'
To obtain your Prescription Drug take your prescription to or have your physician call an AvMed Participating Pharmacy Your physician
should submit prescriptions for Self Administered Injectable Drugs to AvMed s specialty pharmacy Present your prescription along with your
AvMed identification card Pay the following Co payment (as well as the Brand Additional Charge if you or your physician choose a Brand
product when a Generic equivalent is available)
Tier 1
Tier 2
Tier 3
Tier 4
Preferred Generic Drugs
Preferred Brand Drugs
Non Preferred Brand or Generic Drugs
Self Administered Injectable Drugs
$ 15 00 Co payment
$ 30 00 Co payment
$ 50 00 Co payment
$ 75 00 Co payment
ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL
Mail service is a benefit option for maintenance medications needed for chronic or long term health conditions It is best to get an initial
prescription filled at your retail pharmacy Ask your physician for an additional prescription for up to a 90 day supply of your medication to be
ordered through mail service Up to 3 refills are allowed per prescription Pay the following Co payment (as well as the Brand Additional
Charge if you or your physician choose a Brand product when a Generic equivalent is available)
Tier 1
Tier 2
Tier 3
Tier 4
Preferred Generic Drugs $ 45 00 Co payment
Preferred Brand Drugs $ 90 00 Co payment
Non Preferred Brand or Generic Drugs $150 00 Co payment
Self Administered Injectable Drugs are not available through mail service
Prescription Drug Renef its, continued
WHAT IS COVERED'
• Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are
prescnbed by your AvMed physician in accordance with AvMed s coverage criteria AvMed reserves the right 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 independent clinical practice guidelines and standards of care established by
government agencies and medical/pharmaceutical societies
• Your retail Prescription Drug coverage includes up to a 30 day supply of a medication for the listed Co payment Your prescription
may be refilled via retail or mail order after 75% of your previous fill has been used You also have the opportunity to obtain a 90
day supply of medications used for chronic conditions including but not limited to asthma cardiovascular disease and diabetes
from the retail pharmacy for the applicable Co payment per 30 day supply However Pre Authorization may be required for
covered medications
• Your mail order Prescription Drug coverage includes up to a 90 day supply of a routine maintenance medication for the listed Co
payment If the amount of medication is less than a 90 day supply you will still be charged the listed mail order Co payment
• Your Self Administered Injectable Drug coverage extends to many injectable drugs approved by the FDA These drugs must be
prescribed by a physician and dispensed by a retail or specialty pharmacy The Co payment levels for Self Administered Injectable
Drugs apply regardless of provider This means that you are responsible for the appropriate Co payment whether you receive your Self
Administered Injectable Drug from the pharmacy at the doctor s office or during home health visits Self Administered Injectable
Drugs are limited to a 30 day supply
• Your prescription drug coverage includes coverage for injectable contraceptives There is a Co payment of $30 for each injection If
there is an office visit associated with the injection there will be an additional Co payment required for the office visit
• Quantity limits are set in accordance with FDA approved prescribing 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
QUESTIONS' Call your AvMed Member Services Department at 1 800 88 AvMed (1 800 882 8633)
EXCLUSIONS AND LIMITATIONS
• Drugs or medications which do not require a prescription (i e over the counter medications) or when a non prescription alternative is
available
• Medical supplies including therapeutic devices dressings appliances and support garments
• Replacement Prescription Drug products resulting from a lost stolen expired broken or destroyed prescription 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
• Prescription and non prescnption vitamins and minerals except prenatal vitamins
• Nutritional supplements
• Immunizations
• Allergy serums medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer
patients are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co payments or Co
insurance as outlined on the Schedule of Benefits
• Investigational and experimental drugs (except as required by Florida statute)
• Cosmetic products including but not limited to hair growth skin bleaching sun damage and anti wrinkle medications
• Nicotine suppressants and smoking cessation products and services
• Prescription and non prescnption appetite suppressants and products for the purpose of weight loss
• Compounded prescriptions except pediatric preparations
• Medications and immunizations 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 Pre Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures
as outlined in the Group Medical and Hospital Service Contract
AV G100 RX 15/30/50/75 OC 05
MP 3450 (10/05)
AvMED
HEALTH PLANS
OUTPATIENT VISION BENEFITS
Amendment
As of the effective date the following benefits are added for an additional premium
The Plan provides one routine vision examination per contract year with no age limitation subject to a member
copayment of $10 per visit No pre authorization 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)
AVMED
HEALTH PLANS
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 PLNNS
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 ME/PH $250 per admit 04
MP 3522 (10/04)
AvMED
HEALTH P L a N s
Substance Abuse Benefits
Amendment
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)
AVMED
HEALTH
Dui able Medical Fquipnient
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 co -payment, limitations and exclusions remain
as stated in the Certificate of Coverage or Schedule of Co -Payments
*For the treatment of diabetes, coverage for an infusion pump will not apply toward the
annual maximum limitation and shall not be subject to the durable medical equipment
benefit limitation
AV G100 DME 2000 R 06
MP 2149 (4 06)
AVMED
_
HEALTH PLANS
Addendum
Coverage for Mammograms — Waiver of Co -payment
If selected the following provision is hereby modified for an additional premium
Section 10 28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state
Mammograms are covered in accordance with Florzda 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 Co payments
AV Mammogram 05
MP -3228 (12/05)
AVMED
HEALTH PLAYS
DOMESTIC PARTNER
Amendment
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 Fhgibility %Sill be added tot a Domestic Par trier and his of het 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 period prior 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)
AvMED
HEALTH PLANS
VILLV'0E OE KEI xISCAY\E, 5e1ec tic,ri Arnendzrent
As of the Effective Date the above named Subscribing Group has selected the following Amendments
Identifier
AV G100 RX 15/30/50/75 OC 05
AV VISION R 99
AV G100 ETP R 97
AV MH/PH $250 per admit 04
AV SA R 98
AV G l 00 DME 2000 R 06
AV Mammogram 05
AV DP12R02
Amendment Name
Prescription Drug Benefit
Vision Benefit
Elective Termination of Pregnancy
Mental Health Benefit
Substance Abuse
Durable Medical Equipment
Coverge for Mammograms
Domestic Partner
The provisions contained in 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 2006
Subscribing Group
VILLAGE OF KEY BISCAYNE
By
Signature
Name
Title
Date
AV- -SELECTION AMENDMENT -03
AVMED Inc
d/b/a AVMED Health Plan
By
Evis Clavareza
Name
Director of Client Service
Title
Date