HomeMy Public PortalAboutAgreement 05-01-11 - 04-30-12AvMed Health Plans
Group
Medical and Hospital Service
Contract
AV-LG-G 100-2010
MP -5523 (10/10)
TABLE OF CONTENTS
SERVICE AREAS 1
I. GENERAL 1
II. INTERPRETATION 1
III. DEFINITIONS 2
IV. ELIGIBILITY 7
V. ENROLLMENT 9
VI. EFFECTIVE DATE OF MEMBERSHIP 10
VII. MONTHLY PAYMENTS AND CO -PAYMENTS 11
VIII. CONVERSION 12
IX. TERMINATION 14
X. SCHEDULE OF BASIC BENEFITS 20
XI. LIMITATIONS OF BASIC BENEFITS 28
XII. EXCLUSIONS FROM BASIC BENEFITS 29
XIII. COORDINATION OF BENEFITS 34
XIV. SUBROGATION AND RIGHT OF RECOVERY 36
XV. DISCLAIMER OF LIABILITY 37
XVI. GRIEVANCE PROCEDURE 38
XVII. MISCELLANEOUS 43
AV-LG-G 100-2010
MP -5523 (10/10)
AVMED CORPORATE OFFICE
9400 S. DADELAND BLVD.
MIAMI, FL 33156-9004
AVMED MEMBER SERVICES - ALL AREAS
1-800-88 AVMED
(1-800-882-8633)
SERVICE AREAS
MIAMI
9400 South Dadeland Boulevard
Miami, Florida 33156-9004
(305) 671-5437
(800) 432-6676
Miami -Dade
FT. LAUDERDALE
13450 West Sunrise Boulevard
Suite 370
Sunrise, Florida 33323-2947
(954) 462-2520
(800) 368-9189
Broward
Palm Beach
ORLANDO
1800 Pembrook Drive
Suite 190
Orlando, Florida 32810
(407) 539-0007
(800) 227-4848
Lake*
Orange
Osceola
Seminole
GAINESVILLE
4300 Northwest 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
JACKSONVILLE
1300 Riverplace Boulevard
Suite 640
Jacksonville, Florida 32207
(904) 858-1300
(800) 227-4184
Baker
Clay
Duval
Nassau
St. Johns
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
* Coverage available in the following Lake County zip codes: 34736, 34711, 34712, 34713, 34714, 34715 and
34756
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AV-LG-G 100-2010
MP -5523 (10/10)
AvMed, Inc.
d/b/a AvMed HEALTH PLANS
GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT
IN CONSIDERATION of the payment of monthly prepayment subscription amounts as provided herein and of
mutual promises and benefits hereinafter described, AvMed, Inc., a Florida not for profit corporation, d/b/a
AvMed Health Plans, (hereinafter referred to as `AvMed'), and the Subscribing Group as named on the Master
Application attached hereto (hereinafter referred to as `Subscribing Group') agree as follows:
I. GENERAL
The Subscribing Group engages AvMed, 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 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, and including a denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for, 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 Applied Behavior Analysis means the design, implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences, to produce socially significant improvement
in human behavior, including, but not limited to, the use of direct observation, measurement, and
functional analysis of the relations between environment and behavior. Applied behavior analysis
services shall be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an
individual licensed under Chapter 490 or Chapter 491, Florida Statutes.
3.03 Attending Physician means the Participating Physician primarily responsible for the care of a Member
with respect to any particular injury or illness.
3.04 Autism Spectrum Disorder means any of the following disorders as defined in the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:
3.04.01 Autistic disorder;
3.04.02 Asperger's syndrome;
3.04.03 Pervasive developmental disorder not otherwise specified.
3.05 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.
3.06 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.
3.07 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.
3.08 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.
3.09 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.
3.10 Contract Year means the period of 12 consecutive months agreed to by the Subscribing Group and
AvMed on the Master Application, commencing on the effective date of this Contract.
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3.11 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.'
3.12 Co -payment means the portion of the cost, in addition to the prepaid premium amounts, which the
Member 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 -payments directly to the provider of the health services at the time of service.
3.13 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 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.
3.14 Dental Care means dental x-rays, examinations and treatment of the teeth or any services, supplies or
charges directly related to:
3.14.01 the care, filling, removal or replacement of teeth, or
3.14.02 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).
3.15 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.
3.16 Emergency Medical Condition means:
3.16.01 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.
3.16.02 With respect to a pregnant woman:
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.
3.16.03 Examples of Emergency Medical Conditions include, but are not limited to: heart attack,
stroke, massive internal or external bleeding, fractured limbs or severe trauma.
3.17 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.
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3.17.01 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.
3.17.02 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.
3.18 Exclusion means any provision of this Contract whereby coverage for a specific hazard or condition is
entirely eliminated.
3.19 Full -Time Student or Part -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 or Part -Time student in accordance with the requirements of the school.
3.20 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.
3.20.01 The terms `amount of insurance' and `insurance' include the benefits provided under a plan
of self-insurance.
3.20.02 The term `insurer' includes any person, entity or governmental unit providing a plan of self-
insurance.
3.20.03 The terms `policy', `insurance policy', `health insurance policy' and `Group Health
Insurance policy' include plans of self-insurance providing health insurance benefits.
3.21 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.
3.22 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 care personnel
for services covered under this Contract. A visit is limited to a period of 2 hours or less.
3.23 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.
3.24 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'.
3.25 Hospital Services (except as expressly limited or excluded by this Contract) means those services for
registered bed patients that are:
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3.25.01 generally and customarily provided by acute care general Hospitals in accordance with the
standards of acceptable community practice;
3.25.02 performed, prescribed or directed by Participating Providers; and
3.25.03 Medically Necessary for conditions which cannot be adequately treated in Other Health Care
Facilities or with Home Health Care Services or on an ambulatory basis.
3.26 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.
3.27 Injectable Medication 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. Prior authorization is required
for Injectable Medications.
3.28 Limitation means any provision (other than an Exclusion) which restricts coverage under this Contract.
3.29 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.
3.30 Maximum Allowable Payment means the maximum amount that AvMed will pay for any covered
service rendered by a Non -participating Provider or supplier of services, medications or supplies.
3.31 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:
3.31.01 consistent with the symptom, diagnosis, and treatment of the Member's condition;
3.31.02 the most appropriate level of supply and/or service for the diagnosis and treatment of the
Member's condition;
3.31.03 in accordance with standards of acceptable community practice;
3.31.04 not primarily intended for the personal comfort or convenience of the Member, the Member's
family, the physician or other health care providers;
3.31.05 approved by the appropriate medical body or health care specialty involved as effective,
appropriate and essential for the care and treatment of the Member's condition; and
3.31.06 not experimental or investigational.
3.32 Medical Office means any outpatient facility or physician's office in the Service Area utilized by a
Participating Provider.
3.33 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:
3.33.01 generally and customarily provided in the Service Area;
3.33.02 performed, prescribed or directed by Participating Providers; and
3.33.03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and
treatment of injury or illness.
3.34 Member means any Subscriber or Dependent, as described in Sections 3.15 and 3.46, of this Contract.
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3.35 Non -participating Provider means any Health Professional or group of Health Professionals, 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.
3.36 Other Health Care Facility(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 and rehabilitative services, with which AvMed has contracted or established
arrangements for providing these services to Members.
3.37 Participating Provider means any Health Professional (or group of Health Professionals), 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.
3.38 Participating Physician means any Participating Provider licensed under Chapter 458 (physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes.
3.39 Post -Service Claim means any Claim for benefits under the Plan that is not a Pre -Service Claim.
3.40 Pre -Service Claim means any Claim for benefits under the Plan for 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.
3.41 Primary Care Physician means any Participating 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.
3.42 Private Duty Nursing means services provided by registered nurses, licensed practical nurses, or any
other trained attendant whose services ordinarily are rendered to, and restricted to, a particular Member
by arrangements between the Member and the private -duty nurse or attendant. Such persons are
engaged or paid by an individual Member or by someone acting on their behalf, including a hospital that
initially incurs the costs and looks to the Member for reimbursement for such services.
3.43 Relevant Document means any documentation that:
3.43.01 was relied upon in making a benefit determination;
3.43.02 was submitted, considered or generated in the course of making a benefit determination,
without regard to whether it was relied upon in making the determination;
3.43.03 demonstrates compliance with the Plan's administrative process; and
3.43.04 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.
3.44 Service Area means those counties in the State of Florida where AvMed has been approved to conduct
business by the Agency for Health Care Administration (AHCA).
3.45 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 Primary Care Physician.
3.46 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.
3.47 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.
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3.48 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.
3.49 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 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.
3.50 Urgent Medical Condition means a medical condition manifesting itself by acute symptoms that are of
lesser severity than that recognized for an Emergency Medical Condition, such that a prudent layperson
who possesses an average knowledge of health and medicine could reasonably expect the illness or
injury to place the health or safety of the Member or another individual in serious jeopardy, in the
absence of medical treatment within 24 hours. Examples of Urgent Medical Conditions include, but are
not limited to: high fever, dizziness, animal bites, sprains, severe pain, respiratory ailments and
infectious illnesses.
3.51 Urgent Medical Services and Care means medical screening, examination and evaluation in an
ambulatory setting outside of a hospital emergency department, including an Urgent Care Center, Retail
Clinic or PCP office after-hours, on a walk-in basis and usually without a scheduled appointment; and
the covered services for those conditions which, although not life -threatening, could result in serious
injury or disability if left untreated.
3.52 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:
3.52.01 concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and
skilled nursing facilities, including on -site review when appropriate;
3.52.02 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
3.52.03 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.
3.53 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.
IV. ELIGIBILITY
4.01 To be eligible to enroll as a Subscriber, a person must be:
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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.
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
all of the following conditions apply:
a) The child is under the age of 26; and
b) The natural child or stepchild of the Subscriber;
c) 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); or
d) A child for whom the Subscriber has been appointed legal guardian pursuant to a valid
court order; or
e) The newborn child of a covered Dependent of the Subscriber other than the spouse of
the Subscriber (such coverage terminates 18 months after the birth of the newborn
child).
4.02.03 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.
4.02.04 All services applicable for covered Dependent children under this Contract shall be provided
to an enrolled newborn child of the Subscriber, to the enrolled newborn child of a covered
Dependent of the Subscriber other than the spouse 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 (prior to the birth of the child) from the moment of birth (as provided in
Section 10.19). In the case of the newborn adopted child, coverage shall not be effective if
the child is not ultimately placed in the Subscriber's residence, in compliance with Florida
law.
4.02.05 In the event the Subscriber has a child who meets the following requirements, extended
coverage may be available for that child until the end of the calendar year in which the child
reaches age 30:
a) The child is unmarried and does not have a Dependent of his or her own;
b) The child is a resident of Florida or a Full -Time or Part -Time Student; and
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c) The child is not provided coverage as a named Subscriber, insured, enrollee or covered
person under any other group, blanket or franchise health insurance policy or individual
health benefits plan, or is not entitled to benefits under Title XVIII of the Social
Security Act.
d) Such child is not eligible to be covered unless the child was continuously covered by
other creditable coverage without a gap in coverage of more than 63 days.
4.02.06 It is the Subscriber's responsibility to notify AvMed when the child no longer meets these
requirements. Termination of coverage may be retroactively applied if AvMed is not notified
within 31 days. Subscriber agrees to provide supporting documentation upon request by
AvMed.
4.03 No person is eligible to enroll hereunder who has had his coverage previously terminated under Section
9.01.06, 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, while such child is and continues to be both:
4.04.01 incapable of self-sustaining employment by reason of mental retardation or physical
handicap; and
4.04.02 chiefly dependent upon the Subscriber for support and maintenance, provided proof of such
incapacity and dependency is furnished to AvMed by the 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 2 -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.
4.06 Eligible persons must reside within the continental United States, excluding Alaska and Hawaii.
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 employee on behalf of himself
and his eligible Dependents may elect to enroll in the Plan.
5.02 Except as provided for newborns, eligible employees and Dependents who meet the requirements of
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 employees and Dependents may not
enroll until the next open enrollment period of the Subscribing Group.
5.03 Special enrollment periods.
5.03.01
An eligible employee or the employee's eligible Dependent may request to enroll in the Plan
outside of the initial enrollment period and annual open enrollment periods if that individual
loses other coverage or acquires a new dependent as outlined below.
a) If the eligible employee or Dependent declined coverage under the Plan when it was
first offered because of other group health plan or insurance coverage and such
coverage has terminated as a result of:
1) exhaustion of COBRA continuation coverage;
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2) termination of employment or reduction in hours of employment;
3) termination of employer contributions;
4) legal separation, divorce or annulment;
5) change in Dependent status;
6) death of the employee;
7) change in legal custody or legal guardianship; or
8) relocation out of an HMO Service Area.
b) If the eligible employee or Subscriber acquires a new Dependent as a result of:
1) marriage;
2) birth; or
3) adoption or placement for adoption.
c) In the event of a) or b) above, the employee must complete and submit an Enrollment or
Status Change Form within 31 days of the termination of other coverage and provide
proof of continuous coverage under the other plan, or within 31 days of the date the
Dependent becomes eligible (or within 60 days as required for newborns). To enroll a
Dependent, the eligible employee must also enroll or already be enrolled.
5.03.02 Eligible employees and Dependents who are not enrolled, shall be eligible to enroll for
coverage within 60 days following:
a) termination of coverage under Medicaid or Children's Health Insurance Plan (CHIP)
due to loss of eligibility; or
b) determination of eligibility for premium assistance under Medicaid or CHIP.
c) The employee must complete and submit an Enrollment or Status Change Form within
60 days of the date of the termination of Medicaid or CHIP coverage, or within 60 days
of the determination of eligibility for premium assistance under Medicaid or CHIP. To
enroll a Dependent, the eligible employee must also enroll.
5.03.03 Termination resulting from failure to pay premiums on a timely basis or termination of
coverage for cause (due to fraud, intentional misrepresentation, etc.) will not provide a
special enrollment period.
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 17.05)
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:
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6.01 Eligible employees and their eligible 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 otherwise
provided for newborns in Part V) of acquiring the new Dependent, the Subscriber completes and
submits 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, an eligible employee and the
employee's 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, the
employee and Dependents will be required to wait until the next open enrollment period to apply for
coverage.
6.03 Coverage for the newborn child of the Subscriber or the newborn child of the Subscriber's covered
Dependent is effective at birth if Section 4.02.04 and Section 6.02 are complied with.
6.04 If an eligible employee or the employee's eligible Dependents originally declined medical coverage
under the Plan due to other health coverage, and that coverage is subsequently terminated as a result of a
loss of eligibility for such coverage or the termination of any employer contributions for such coverage,
the employee and the employee's Dependents will be eligible to enroll in the Plan. To enroll, the
employee must complete and submit an Enrollment Form within 31 days of the termination of such
other coverage. The effective date of any coverage provided by AvMed will be the first day of the
month following the date of enrollment. If the employee fails to enroll within 31 days after the loss of
such other coverage, the employee and the employee's Dependents must wait until the next open
enrollment period to apply for coverage.
6.05 If an employee or the employee's Dependents are eligible for coverage but not enrolled, and experience
a termination of coverage under Medicaid or CHIP due to loss of eligibility, or are determined to be
eligible for premium assistance under Medicaid or CHIP, the employee and the employee's Dependents
will be eligible to enroll in the Plan. To enroll, the employee must complete and submit an Enrollment
Form within 60 days of the termination of coverage or the determination of eligibility for assistance.
The effective date of any coverage provided by AvMed will be the first day of the month following the
date of enrollment. If the employee fails to enroll within 60 days after the loss of such coverage or the
determination of such eligibility, the employee and the employee's Dependents must wait until the next
open enrollment period to apply for coverage.
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
17.17.
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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 the 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 Medication, Vision and Elective Termination of
Pregnancy amendments.
7.04 Member shall pay premiums, applicable supplemental charges or Co -payments as provided in this
Contract and applicable Schedule of Benefits. If the Member fails to pay the applicable premiums, upon
10 days written notice from AvMed to the 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 Sections 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 3.11), unless there is a
replacement of discontinued group coverage by similar group coverage within 31 days.
8.01.01 The converting Subscriber and each of the Subscriber's eligible Dependents who are
converting must be Members of the Plan in good standing on the date when their coverage
terminates under this Group Contract and all such Subscribers and Dependents, after
complying with Section 8.01.02 below, shall be covered under the Individual Conversion
Contract.
8.01.02 A completed Status Change Form requesting conversion shall be sent to 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.
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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 Section 8.01.02 above; or
b) A spouse whose coverage would terminate, or a spouse and children whose coverage
would otherwise terminate at the same time, or a child with respect to himself, by
reason of ceasing to be a qualified family member, may convert and must comply with
Section 8.01.02 above; or
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 Section 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 the
Subscriber made 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 coverage
under this Contract occurred for any of the following reasons:
8.03.01 Failure to pay any required premium or contribution unless such nonpayment of premium
was due to acts of an employer or person other than the individual;
8.03.02 Replacement of any discontinued group coverage by similar group coverage within 31 days;
8.03.03 Fraud or material misrepresentation in applying for any benefits under this Contract (see
Section 9.01.06);
8.03.04 Willful and knowing misuse of AvMed's identification card by the Member;
8.03.05 Willfully and knowingly furnishing incorrect or incomplete information to AvMed for the
purpose of fraudulently obtaining coverage or benefits from AvMed; or
8.03.06 Termination from coverage under this Contract in accordance with Section 9.01.06.
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 Dependents 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:
AvMed
Accounts Receivable Department
Suite 510
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9400 South Dadeland Blvd.
Miami, Florida 33156
8.04.01 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.
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 8.03:
a) Upon the loss of a 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, on the last day of the month for which the
monthly premium was paid.
a) Upon failure of the Subscriber to make payment of any premium contributions or
applicable supplemental charges required by Section 7.04 of this Contract, coverage
shall automatically terminate for the Subscriber and all Dependents on the tenth day
after written notice from AvMed.
b) 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.
9.01.03 Termination of Group Contract by Subscribing Group. Subscribing Group may terminate
this Group Contract on the Contract anniversary date by giving written notice to AvMed 15
days prior to the anniversary date. In such event, benefits hereunder shall terminate for all
Members on the Contract expiration date.
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9.01.04 Early termination of Group Contract by Subscribing Group. Subscribing Group may
terminate this Group Contract by giving at least 60 days written notice to AvMed. In such
event, benefits hereunder shall terminate for all Members on the date specified by the Group
in their written notice to AvMed and for which premium was paid.
9.01.05 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 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 Section 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.
9.01.06 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 2 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 2 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; or
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.
e) 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:
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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
employees who are Subscribers under this Contract.
9.02.04 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 coverage under this Plan ends, Members will automatically receive a
Certificate of Group Health Plan Coverage. The certificate may be taken to another health care plan to
receive credit for coverage under this Plan if the other health care plan has a pre-existing condition limit.
Requests for a Certificate of Group Health Plan Coverage may be made anytime during the 24 -month
period after the date coverage under this Plan has ended.
9.04 Continuation Coverage under COBRA. Under certain provisions of COBRA, a Subscriber or the
Subscriber's covered Dependents may elect continued coverage under the Plan if coverage is lost due to
a qualifying event.
9.04.01 Eligibility. Subscribers or their 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 the Subscriber's hours of employment;
b) Termination of the Subscriber's 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
the Subscribers indicates he will not return to work or the last day of the FMLA leave;
or
d) The Subscriber or a Dependent first become entitled to Medicare or covered under
another group health plan prior to the Subscriber's loss of coverage due to termination
of employment or reduction in hours.
e) In addition, a Subscriber's Dependents will become eligible for COBRA continuation
coverage after any of the following qualifying events occur to cause a loss of Plan
coverage:
1) The Subscriber's death;
2) Divorce or legal separation from the Subscriber;
3) The Subscriber first becomes entitled to Medicare after a loss of coverage due to
termination of employment or reduction in hours; or
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4) The Subscriber's Dependent child no longer qualifies as a Dependent under the
Plan.
f) 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.
9.04.02 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 the Subscriber's employer and will send the Subscriber an election form.
To continue Plan coverage, the election form must be returned within 60 days from the later
of the date the form is received or the date coverage ends due to a qualifying event.
a) If divorce, legal separation, loss of Dependent status or entitlement to Medicare under
the Plan occurs, the Subscriber or 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 the Subscriber or 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 of the Subscriber and Dependents to continue coverage.
b) After receiving this notice, the Plan Administrator will send the Subscriber an election
form within 14 days. If the Subscriber or 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 the form is received or the date coverage ends due to the
qualifying event.
9.04.03 Cost. If continuation coverage is elected, the Subscriber 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.
a) If a Subscriber or Dependent is Social Security disabled (Social Security disability
status must occur as defined by Title II or Title XVI of the Social Security Act), the
Subscriber may elect to continuation coverage for the disabled person only, or for some
or all of COBRA eligible family members for up to 29 months if the Subscriber's
employment is terminated or hours are reduced. The Subscriber must pay 102% of the
cost of coverage for the first 18 months of COBRA continuation coverage and 150% of
the cost of 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
termination of the Subscriber's employment or reduction in hours.
b) 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. (The first
payment is due no later than 45 days after the election to continue coverage, and must
cover the period of time back to the first day of COBRA continuation coverage).
9.04.04 Duration. COBRA Continuation Coverage can be extended for:
a) 18 months if coverage ended due to a reduction in a Subscriber's work hours or
termination of employment and the Subscriber or one of his covered Dependents is not
Social Security disabled within 60 days of the date of the loss of coverage due to
termination of employment or reduction in hours, the Medicare entitled person may
elect up to 18 months of COBRA. If the Subscriber is that Medicare entitled person,
the Subscriber's Dependents may elect COBRA for the longer of 36 months from the
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Subscriber's prior Medicare entitlement date, or 18 months from the date of the
termination or reduction in hours; or
b) 36 months for the Subscriber's Dependents, if the Dependents lose eligibility for
medical coverage due to the Subscriber's death, divorce or legal separation from the
Subscriber, the Subscriber's entitlement to Medicare after termination or reduction in
hours, or the Subscriber's Dependent child ceasing to qualify as a Dependent under the
Plan; or
c) 29 months if the Subscriber's coverage is lost due to termination of employment or
reduction in hours and the Subscriber 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, the Subscriber 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 the
Subscriber's covered family members; or
d) To be eligible for extended coverage due to Social Security disability, a Subscriber 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 the Subscriber 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, the Subscriber 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.
e) 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:
1) first becomes covered under another group health plan after the loss of coverage
due to a 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,
provided contributions for COBRA coverage continue to be paid. Coverage may
only continue for the remainder of the original COBRA period;
2) fails to make required contributions when due;
3) first becomes entitled to Medicare benefits after the initial COBRA qualifying
event; or
4) 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, a Subscriber 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 the Subscriber's child, to care for the newborn child, or for placement of a
child in the Subscriber's home for adoption or foster care;
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b) to care for a spouse, child or parent with a serious health condition; or
c) for the Subscriber's own serious health condition.
d) If the FMLA leave is paid, such pay will be reduced by the Subscriber's before -tax
contributions as usual for the coverage level in effect on the date FMLA leave begins.
If FMLA leave is unpaid, the Subscriber will be required to pay contributions directly to
the employer until returning to active pay status.
e) If the Subscriber notifies the employer that he or she is terminating employment during
FMLA leave, coverage will end on the date of notification. If the Subscriber does not
return to work on the expected FMLA return date, and the employer is not notified of
the intent either to terminate employment or to extend the period of leave, coverage will
end on the date the Subscriber was expected to return.
f) Plan elections may not be changed during FMLA leave unless an open enrollment
occurs or the FMLA leave is paid and the Subscriber has 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 a Subscriber is absent from work due to military service,
continuation coverage under the Plan (including coverage for enrolled Dependents) may be
elected for up to 18 months from the first day of absence (or if earlier, until the day after the
date the Subscriber is required to apply for or return to active employment with the employer
under the Uniformed Services Employment and Reemployment Rights Act of 1994
(USERRA)). The Subscriber's contributions for continued coverage will be the same as for
similarly situated active participants in the Plan.
a) Whether or not coverage is continued during military service, a Subscriber may
reinstate coverage under the Plan option elected on return to employment under
USERRA. The reinstatement will be without any waiting period otherwise required
under the Plan, except to the extent that any required waiting period was not completed
prior to the start of the military service.
9.06 Conversion after Continuation Coverage. See Section 9.02.
9.07 Extension of benefits. In the event this Contract is terminated for any reason, except nonpayment of
premium or as set forth in Section 9.07.03, such termination shall be without prejudice to any
continuous losses to a 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 3.48, of the Member and shall be limited to payment for the treatment of a specific
accident or illness incurred while coverage under this Contract was effective.
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
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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; or
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 Chapter 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 Section 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 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. Any covered service for which the member is
seeking reimbursement, must be submitted to the Plan within one year from the date of service to be considered.
Members must understand that services will not be covered if they are not, in AvMed's 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 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. Any Member requiring medical, Hospital or ambulance
services for emergencies (as described in Sections 3.16 and 3.17), either while temporarily outside the Service
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Area or within the Service Area but before they can reach a Participating Provider, may receive the emergency
benefits as specified in Section 10.11.
The following services require prior authorization from AvMed:
• Inpatient admissions
• All Home Health Care Services
• Complex diagnostic procedures
• Surgical procedures or services performed in an outpatient Hospital, Hospital -affiliated ambulatory
surgery center or free-standing ambulatory surgery center
• All medications administered in an outpatient Hospital or infusion therapy setting
• Select medications administered in a physician's office
• Care rendered by Non -participating Providers (except for Emergency Medical Services and Care)
• Transplant services
• Dialysis services
For more information about which services require prior authorization, contact AvMed at 1-800-882-8633.
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 Part X 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 10.11, 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.
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 www.avmed.org. Notwithstanding the printed booklet, the names and addresses of Participating
Providers on file with AvMed at any 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.
Each Member shall select a Primary Care Physician (PCP) upon enrollment. A pediatrician may be selected as a
PCP for a child. In the event a PCP selection is not made upon enrollment, AvMed will assign one. Members
must notify and receive approval from AvMed prior to changing PCPs. Such change will become effective on
the first day of the month after AvMed is notified. Primary Care Physician selection cannot be changed more
than once per month. Health Professionals may from time to time cease their affiliation with AvMed. In such
cases, Members will be required to receive services from another participating Health Professional.
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, any payment that AvMed may make will not exceed the Maximum
Allowable Payment and the Member will be responsible for reimbursing AvMed any Maximum Allowable
Payment made for the services and supplies received.
NOTE: If you currently reside in a continuing care facility or a retirement facility consisting of a nursing home
or assisted living facility and residential apartments, this notice applies to you. You may request to be referred to
that facility's skilled nursing unit or assisted living facility. If the request for referral is denied, you may use the
appeal process described in Part XVI. Grievance Procedures.
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 Ambulance services as follows:
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10.01.01 Local professional air/ground ambulance transport for emergency services to the nearest
emergency department appropriately staffed and equipped to treat a medical condition;
10.01.02 Ground transportation to an alternative level of care when associated with an approved
Hospital confinement; and
10.01.03 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.
10.01.04 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.
10.02 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.
10.03 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.
10.04 Dermatological services. AvMed will cover office visits to a participating dermatologist for Medically
Necessary covered services subject to Sections 3.31 and 3.52. No prior referral is required for these
services.
10.05 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 10.10.05. Diabetes outpatient self -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. See also Section 10.06.
10.06 Diabetic supplies. Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing
Group's supplemental prescription medication benefits. In the event a Subscribing Group does not
purchase supplemental prescription medication benefits, insulin, insulin syringes, lancets, and test strips
are covered subject to a $25 Co -payment per item for a 30 -day supply.
10.07 Diagnosis and treatment of Autism Spectrum Disorder through speech therapy, occupational therapy,
physical therapy, and Applied Behavior Analysis services for an individual under 18 years of age or an
individual 18 years of age or older who is in high school who has been diagnosed as having a
developmental disability at 8 years of age or younger.
10.07.01 Coverage shall be limited to services that are prescribed by the treating physician in
accordance with a treatment plan. The treatment plan required shall include, but is not
limited to, a diagnosis, the proposed treatment by type, the frequency and duration of
treatment, the anticipated outcomes stated as goals, the frequency with which the treatment
plan will be updated, and the signature of the treating physician. Coverage for these services
shall be limited to $36,000 annually and may not exceed $200,000 in total benefits.
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10.08 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.
10.09 Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADHD).
Coverage is subject to applicable Co -payments and coverage limitations as outlined on the Schedule of
Benefits. Covered services do not include those that are primarily educational or training in nature.
10.10 Durable Medical Equipment (DME). This Contract provides benefits, when Medically Necessary, for
the purchase or rental of such DME that:
10.10.01 can withstand repeated use (i.e. could normally be rented and used by successive patients);
10.10.02 is primarily and customarily used to serve a medical purpose;
10.10.03 generally is not useful to a person in the absence of illness or injury; and
10.10.04 is appropriate for use in a patient's home.
10.10.05 Some examples of DME are: hospital beds, crutches, canes, walkers, wheelchairs, oxygen,
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.
10.10.06 Oxygen is covered when Medically Necessary pursuant to AvMed's coverage guidelines,
which are available free of charge upon request. The type of oxygen delivery system
covered (stationary, portable, ambulatory) is based on the Member's activity status. Initial
coverage is contingent upon arterial blood gas results. Reassessment of oxygen needs
through pulse oximetry at rest and after exercise is required and must be performed by an
independent respiratory provider at three months after the initiation of therapy and then
yearly in order to re -qualify coverage of oxygen therapy.
10.10.07 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.
10.11 Emergency services. AvMed will cover all necessary physician and Hospital Services for Emergency
Medical Services and Care. See Sections 3.16 and 3.17. In the event Hospital inpatient services are
provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital,
Member or designee, within 24 -hours of the inpatient admission if reasonably possible. AvMed may
elect to transfer the Member to a Participating Provider as soon as it is medically appropriate to do so.
AvMed will pay the Maximum Allowable Payment to a Non -participating Provider only for those
services rendered before a Member's condition permits him or her 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.
10.12 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
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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.
10.13 Home Health Care Services (Skilled Home Health Care). Home Health Care Services (as defined in
Section 3.22) are covered when ordered by and under the direction of the Member's Attending
Physician. Services are limited to a period of two hours or less per visit, and 60 visits per calendar year.
Physical, occupational or speech therapy services provided in the home are limited as noted in Section
10.26. 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.
10.14 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,
medications, biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory
therapy, and administration of blood or blood plasma. See Section 10.11 with regard to inpatient
admission following Emergency Medical Services and Care.
10.15 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 6 months or less.
10.16 Major organ transplants at a facility deemed appropriate and authorized by AvMed, as well as
associated immunosuppressant medications are covered except those deemed experimental. See Section
12.15.
10.17 Mammograms are covered in accordance with Florida Statutes and the U.S. Preventive Services Task
Force (USPSTF) preventive services recommendations (Grade A and B). One baseline mammogram is
covered for female Members between the ages of 35 and 39. A mammogram is available every 2 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.
10.17.01 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.
10.18 Mastectomy surgery when performed for breast cancer. Coverage for post -mastectomy reconstructive
surgery shall include:
10.18.01 reconstruction of the breast on which the mastectomy has been performed;
10.18.02 surgery and reconstruction on the other breast to produce a symmetrical appearance; and
10.18.03 prostheses and physical complications during all stages of mastectomy including
lymphedemas.
10.18.04 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. The Attending Physician, after consultation with the covered
patient, may choose that the outpatient care be provided at the most medically appropriate
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setting, which may include the hospital, treating physician's office, outpatient center or home
of the covered patient.
10.18.05 Coverage is subject to any applicable Co -payments and will require prior authorization of
services as applicable to other surgical procedures or hospitalizations under the Plan.
10.19 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 Section 4.02.04, 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.
10.20 Non -participating Provider services. 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 will be made not to exceed the Maximum Allowable Payment for such covered services
rendered by a Non -participating Provider. 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.
10.21 Obstetrical and gynecological care. 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. 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:
10.21.01 Hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours
following a cesarean section;
10.21.02 The Attending Physician does not need to obtain authorization from AvMed to prescribe a
Hospital stay of this length;
10.21.03 AvMed will cover an extended stay, if Medically Necessary; however, the physician or
Hospital must pre -certify the extended stay.
10.21.04 Shorter Hospital stays are permitted if the Attending Physician, in consultation with the
mother, determines that to be best course of action. Coverage for maternity care is subject to
applicable Co -payments and all other Plan limits and requirements.
10.22 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. 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.
10.23 Osteoporosis diagnosis and treatment when Medically Necessary for high -risk individuals, including
but not limited to estrogen -deficient individuals, individuals with vertebral abnormalities, individuals on
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long-term glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism and
individuals with a family history of osteoporosis.
10.24 Other Health Care Facility(ies). All routine services of Other Health Care Facilities (see Section
3.36), 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 Skilled Home Health
Care Services or on an ambulatory basis.
10.25 Outpatient therapeutic services. Covered health services for therapeutic treatments received on an
outpatient basis in the home, physician's office, Other Health Care Facility or Hospital, including
intravenous chemotherapy or other intravenous infusion therapy and Injectable Medications. Self -
Administered Injectable Medications are only a covered benefit when included in the supplemental
prescription medication benefits. See Section 12.30.
10.26 Physical, occupational or speech therapy:
10.26.01 Short-term physical and occupational therapy provided in an outpatient or home care setting
is covered to improve or restore physical functioning following disease, injury or loss of a
body part. Impairments, functional limitations and disabilities identified are addressed by
the design and implementation of a therapeutic intervention tailored to the specific needs of
the individual patient. Physical and occupational therapy are covered when performed with
the expectation of restoring the patient's level of function which has been lost or reduced by
injury or illness.
10.26.02 Speech therapy provided in the outpatient setting, including the home, is covered only when
existing speech function has been impaired by a disease or injury and there is a reasonable
expectation that improvement or restoration of speech function can be attained. Non-
organic/functional disorders, which are considered speech and language problems with no
identifiable medical cause, are not covered, except for the initial evaluation to determine the
root cause.
10.26.03 Outpatient physical, occupational and/or speech therapies are covered up to a combined total
of 30 visits per calendar year, including evaluations. Therapy performed repetitively to
maintain a level of function is not covered. Maintenance begins when the therapeutic goals
of a treatment plan have been achieved, or when no additional functional progress is
apparent or expected to occur. Therapy is covered for the treatment of Autism Spectrum
Disorder subject to Section 10.07. Long-term physical, occupational or speech therapy,
rehabilitation, or other treatment is not covered.
10.27 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 10.26) are covered 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.
10.28 Physician care: outpatient
10.28.01 Diagnosis and treatment. All Medical Services rendered by Participating Physicians and
other Health Professionals, are covered when Medically Necessary and 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
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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.
10.28.02 Preventive and health maintenance services. Services of Participating Providers for
illness prevention and health maintenance, including items or services that have an A or B
rating in current recommendations of the U.S. Preventive Services Task Force (USPSTF);
immunizations recommended by the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention; evidence -informed preventive care and
screenings for infants, children, and adolescents as provided for in the comprehensive
guidelines supported by the Health Resources and Services Administration (HRSA); and
additional preventive care and screening (with respect to women) provided for in guidelines
supported by the Health Resources and Services Administration.
10.29 Prescription medication benefits. Allergy serums and chemotherapy for cancer patients are covered.
Coverage for insulin and other diabetic supplies is described in Section 10.06 above. Other retail
prescription medications are a covered benefit only when the Subscribing Group Contract includes
supplemental prescription medication benefits; coverage is subject to the Co-payment/Co-insurance
provisions outlined therein.
10.30 Prosthetic devices. This Contract provides benefits, when Medically Necessary, for prosthetic devices
designed to restore bodily function or replace a physical portion of the body. Coverage for prosthetic
devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. 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,
including prosthetic devices for Deluxe, Myo-electric and electronic prosthetic devices. 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.
10.31 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.
10.31.01 The Member may obtain a second medical opinion from any physician who is within
AvMed's Service Area. If a Participating Physician is chosen, there is no prior authorization
requirement. The Member pays only the applicable Co -payment or Deductible and Co-
insurance. If a non -participating physician is chosen, the service is subject to prior
authorization requirements. The Member is also responsible for 40% of the amount of the
Maximum Allowable Payment associated with the consultation.
10.31.02 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.
10.31.03 AvMed may limit second medical opinions in connection with a particular diagnosis or
treatment to three per calendar year, if AvMed deems additional opinions to be an
unreasonable over -utilization by the Member.
10.32 Spinal manipulations will be covered only when Medically Necessary and prescribed by a
Participating Physician or by self -referral to a Participating Physician.
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10.33 Supplies. Ostomy, urostomy and wound care supplies are covered when Medically Necessary. Wound
care supplies are covered as part of an approved treatment plan, when one of the following criteria is
met:
10.33.01 Treatment of a wound caused by or treated by a surgical procedure; or
10.33.02 Treatment of a would that required debridement.
10.33.03 Provision of ostomy, urostomy and wound care supplies is limited to a one -month supply
every 30 days. Coverage is limited to $2,500 per calendar year, subject to applicable Co -
payments. 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.
10.34 Urgent Care services. All necessary and covered services received in an Urgent or Immediate Care
Center, Retail Clinic or a Primary Care Physician's office after-hours for conditions as described in
Section 3.51 will be covered by AvMed. 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.
10.35 Ventilator dependent care. With prior authorization by AvMed, ventilator dependent care (see Section
3.53) is covered up to a total of 100 days lifetime maximum benefit.
XI. LIMITATIONS OF BASIC BENEFITS
The rights of Members and obligations of Participating Providers hereunder are subject to the following
Limitations:
11.01 Cardiac rehabilitation. Coverage is limited to a maximum of 18 visits per calendar year.
11.02 Diagnosis and treatment of Autism Spectrum Disorder. Coverage for the diagnosis and treatment of
Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total
benefits.
11.03 Durable Medical Equipment (DME). Coverage is limited to $2,000 per calendar year.
11.04 Home Health Care Services (Skilled Home Health Care) visits are limited to a period of two hours or
less per visit and 60 visits per calendar year.
11.05 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.
11.06 Licensed dietitians/nutritionists. 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 12.18.
11.07 Major Organ Transplant services. Transportation for transplant services is administered through
Optum Health, an AvMed third party partner. Charges are limited to $200 per day up to $10,000 lifetime
maximum for a companion to accompany the Member (or 2 companions when the patient is a minor)
and the member has to travel greater than a 50 mile radius to receive the transplant. This service is
available only when the transplant is authorized at one of AvMed's contracted transplant facilities.
11.08 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.
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11.09 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 for conditions that cannot be adequately treated
with Home Health Care Services or on an ambulatory basis, when a Member is admitted to such a
facility following discharge from a Hospital.
11.10 Physical, occupational or speech therapy. Coverage of outpatient physical, occupational and speech
therapy is limited to a combined total of 30 visits per calendar year including evaluations.
11.11 Prosthetic devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular
prostheses and cochlear implants.
11.12 Second medical opinions. AvMed may limit second medical opinions in connection with a particular
diagnosis or treatment to three per calendar year, if AvMed deems additional opinions to be an
unreasonable over -utilization by the Member.
11.13 Substance abuse treatment. Treatment for alcohol and drug abuse is limited to inpatient services for
acute detoxification and the treatment of other medical sequelae of such abuse. Alcohol or drug
rehabilitation services are not covered.
11.14 Supplies. Provision of ostomy, urostomy and wound care supplies is limited to a one -month supply
every 30 days. Coverage is limited to $2,500 per calendar year.
11.15 Ventilator dependent care. The total benefit for ventilator dependent care is limited to a lifetime
maximum of 100 calendar days.
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 Aids or devices that assist with nonverbal communications, including but not limited to
communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal
Digital Assistants (PDAs) Braille typewriters, visual alert systems for the deaf and memory books.
12.02 Armed forces service -connected medical care for both sickness and injury.
12.03 Autopsy or postmortem examinations and associated services.
12.04 Breast reduction or augmentation. Surgery for the reduction or augmentation of the size of the breasts
except as required for the comprehensive treatment of breast cancer.
12.05 Complementary or alternative medicine including but not limited to, acupuncture; aromatherapy,
Ayurvedic medicine such as lifestyle modifications, purification and massage therapies; behavioral
training, biofield therapies; bioelectromagnetic applications and medicine; biofeedback; chelation
therapy; cognitive therapy; environmental medicine including the field of clinical ecology; herbal
therapies; homeopathic medicine and counseling; hypnotherapy; mind -body interactions such as
meditation, imagery, yoga, dance, and art therapy; manual healing methods such as the Alexander
technique, massage therapy including but not limited to:, craniosacral balancing, Feldenkrais method,
Hellerwork, reflexology, Rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger -point
myotherapy, and polarity therapy; naturopathic medicine; prayer and mental healing; Reichian therapy,
Reiki, self -care and self-help training; sex therapy, SHEN therapy, sleep therapy, therapeutic touch;
thermography; traditional Chinese medicine including acupuncture and vocational rehabilitation.
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12.06 Complications of any non -covered service, including the evaluation or treatment of any condition that
arises as a complication of a non -covered service.
12.07 Cosmetic, surgical or non -surgical procedures which are undertaken primarily to improve or
otherwise modify the Member's external appearance are excluded, except for 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. 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 10.19); 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.
12.08 Cosmetics, dietary supplements, nutritional formulae, health or beauty aids.
12.09 Custodial Care (as defined in Section 3.13).
12.10 Dental Care, as defined in Section 3.14, for any condition except:
12.10.01 Services, supplies or appliances for Dental Care necessary to promptly repair (but not
replace), sound natural teeth required as a result of and directly related to an accidental
injury sustained while covered under the Plan. Treatment must begin 90 days from date of
injury. Such services are limited to $1,000 per calendar year;
12.10.02 Reconstructive jaw surgery for the treatment of deformities that are present and apparent at
birth; or
12.10.03 Services for the treatment of tumors or full mouth extraction when required before radiation
therapy.
12.10.04 Treatment must be completed within nine months from date of injury.
12.11 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities,
behavioral problems and developmental delays. 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.
12.12 Durable Medical Equipment (DME) items that are not covered include, but are not limited to the
following:
12.12.01 Bed related items: bed trays, over the bed tables, bed wedges, pillows, custom bedroom
equipment, mattresses, including non -power mattresses, custom mattresses and posturepedic
mattresses;
12.12.02 Bath related items: bath lifts, non -portable whirlpools, bathtub rails, toilet rails, raised toilet
seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, and spas;
12.12.03 Chairs, lifts and standing devices: computerized or gyroscopic mobility systems, roll about
chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts
(mechanical or motorized — manual hydraulic lifts are covered if patient is 2 -person transfer),
and auto tilt chairs;
12.12.04 Fixtures to real property: ceiling lifts and wheelchair ramps;
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12.12.05 Car/van modifications;
12.12.06 Air quality items: room humidifiers, vaporizers, air purifiers and electrostatic machines;
12.12.07 Blood/injection related items: blood pressure cuffs, centrifuges, nova pens and needle less
injectors; and
12.12.08 other equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic -
controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair
gliders, elevators, saunas, any exercise equipment and diathermy machines.
12.13 Emergency room services for non -emergency purposes. See Sections 3.16 and 3.17.
12.14 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.
12.15 Experimental and/or investigational procedures, except for bone marrow transplants, as approved per
Section 59B-12.001, Florida Administrative Code, and cancer clinical trials as set forth in the Florida
Clinical Trials Agreement, effective July 1, 2010. For the purposes of this Contract, a medication,
treatment, device, surgery or procedure may be determined to be experimental and/or investigational if
any of the following applies:
12.15.01 The FDA has not granted the approval for general use;
12.15.02 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;
12.15.03 There is no consensus among practicing physicians that the medication, treatment, therapy,
procedure or device is safe or effective for the treatment in question or such medication,
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
12.15.04 Such medication, 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 Eye care including:
12.16.01 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);
12.16.02 training or orthoptics, including eye exercises; or
12.16.03 radial keratotomy, refractory keratoplasty, Lasik surgery or any other corneal surgical
procedure to correct refractive error.
12.17 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.
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12.18 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.
12.19 Gender reassignment surgery as well as any service, supply, or medical care associated with gender
reassignment or gender identity disorders.
12.20 Home monitoring devices and measuring devices (other than apnea monitors), and any other
equipment or devices for use outside the Hospital.
12.21 Hospital Services that are associated with excluded surgery or Dental Care.
12.22 Hearing examinations for Members 18 years of age or older for the purpose of determining the need
for hearing correction.
12.23 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. Medications for the treatment of infertility are not covered.
12.24 Immunizations and medications for the purpose of foreign travel or employment.
12.25 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions caused
by congenital or developmental deformity, disease, or injury.
12.26 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.
12.27 Medical supplies including, but not limited to: pre -fabricated splints, Thromboemboletic/Support hose
and all other bandages, except as provided in Sections 10.22 and 10.33.
12.28 Non -participating Providers. 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 3.16 and 3.17),
including hospital care from a non -participating Attending Physician or a non -participating Hospital, if
elected by a member. In such circumstances, 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.
12.29 Organ donor treatment and services. 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 family members and the National Bone Marrow Donor Program. Post -transplant donor
complications will not be covered.
12.30 Over-the-counter medications, and prescription medications not otherwise covered including all
contraceptives (medications and devices), hypodermic needles and syringes and Injectable Medications
except insulin and insulin syringes for the treatment of diabetes as outlined in Section 10.06.
12.31 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
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ambulance services that are provided for in Section 10.01), air conditioners, humidifiers, dehumidifiers,
and air purifiers or filters.
12.32 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.
12.33 Physical, occupational, speech and all other therapies for chronic conditions. Maintenance therapy
is not covered. Maintenance therapy begins when the therapeutic goals of a treatment plan have been
met and/or no further functional progress is expected. Speech therapy for non -organic or functional
disorders is not covered, except for the initial evaluation to determine the root cause. Examples include
attention deficit disorder, developmental delay, mental retardation, and Down's syndrome. Abnormal
speech pathology, including but not limited to lisping and stuttering, is not covered.
12.34 Private duty nursing services.
12.35 Rehabilitation programs. Alcohol or substance abuse rehabilitation, vocational rehabilitation,
pulmonary rehabilitation, long term rehabilitation, or any other rehabilitation program.
12.36 Removal of benign skin lesions including, but not limited to, warts, moles, skin tags, lipomas, keloids
and scars is not covered, even with a recommendation or prescription by a physician.
12.37 Reversal of sterilization procedures.
12.38 Sexual dysfunction. All medications, devices, and other forms of treatment related to a diagnosis of
sexual dysfunction, regardless of etiology.
12.39 Smoking cessation. 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).
12.40 Substance Abuse Treatment. Treatment for chronic alcoholism and chronic drug addiction, except
those services offered as a basic health service. 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.
12.41 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and vascular grafts. Dental
appliances, other corrective lenses and hearing aids, including the professional fee for fitting them, are
not covered.
12.42 Temporomandibular Joint Dysfunction (TMJ). Services related to the diagnosis/treatment of TMJ
except when Medically Necessary; all dental treatment for TMJ.
12.43 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.
12.44 Travel expenses including expenses for ambulance services to and from a physician or Hospital except
in accordance with Section 10.01.
12.45 Treatment of a condition resulting from:
12.45.01 participation in a riot or rebellion;
12.45.02 engagement in an illegal occupation;
12.45.03 participation in, or commission of, any act punishable by law as a felony whether or not the
individual is charged or convicted.
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12.46 Ventilator dependent care, except as provided in Part X (Schedule of Basic Benefits) for 100 days
lifetime maximum benefit.
12.47 Workers' Compensation benefits. 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.
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 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 and Children's Health Insurance Program (CHIP)
benefits.
13.02 If any covered person is eligible for services or benefits under 2 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
the 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
Chapter 627.4235, Florida Statutes:
13.03.01 The benefits of a policy or plan that 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 Section 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.
c) 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
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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.
d) However, if the specific terms of a court order state that one of the parents is
responsible for the health care expenses of the child and if the entity obliged to pay or
provide the benefits of the 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 Section shall not apply.
13.03.05 If none of the rules in Sections 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 Chapter 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
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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 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.
13.07 If the amount of the payments made by AvMed is more than it should have paid under the provisions of
this Part XIII, it may recover the excess from one or more of the persons it has paid or for whom it has
paid; or any other person or organization that may be responsible for the benefits or services provided
for the Member. The `amount of the payments made' includes the reasonable cash value of any benefits
provided in the form of services.
13.08 In the event the Subscribing Group offers Health Reimbursement Arrangements (HRA) in connection
with this Plan, the HRA is intended to pay solely for otherwise un-reimbursed medical expenses.
Accordingly, it shall not be considered a group health plan for coordination of benefits purposes, and its
benefits shall not be taken into account when determining benefits payable under any other plan.
XIV. SUBROGATION AND RIGHT OF RECOVERY
14.01 If AvMed provides health care benefits under this Contract to a Member for injuries or illness for which
another party is or may be responsible, then AvMed retains the right to repayment of the full cost of all
benefits provided by AvMed on behalf of the Member that are associated with the injury or illness for
which another party is or may be responsible. AvMed's rights of recovery apply to any recoveries made
by or on behalf of the Member from the following third -party sources, as allowed by law, including but
not limited to: payments made by a third -party tortfeasor or any insurance company on behalf of the
third -party tortfeasor; any payments or awards under an uninsured or underinsured motorist coverage
policy; any worker's compensation or disability award or settlement; medical payments coverage under
any automobile policy, premises or homeowners medical payments coverage or premises or
homeowners insurance coverage; any other payments from a source intended to compensate a Member
for injuries resulting from an accident or alleged negligence. For purposes of this Contract, a tortfeasor
is any party who has committed injury, or wrongful act done willingly, negligently or in circumstances
involving strict liability, but not including breach of contract for which a civil suit can be brought.
14.02 Member specifically acknowledges AvMed's right of subrogation. When AvMed provides health care
benefits for injuries or illnesses for which a third party is or may be responsible, AvMed shall be
subrogated to the Member's rights of recovery against any party to the extent of the full cost of all
benefits provided by AvMed, to the fullest extent permitted by law. AvMed may proceed against any
party with or without the Member's consent.
14.03 Member also specifically acknowledges AvMed's right of reimbursement. This right of reimbursement
attaches, to the fullest extent permitted by law, when AvMed has provided health care benefits for
injuries or illness for which another party is or may be responsible and the Member and/or the
Member's representative has recovered any amounts from the third party or any party making payments
on the third party's behalf By providing any benefit under this Contract, AvMed is granted an
assignment of the proceeds of any settlement, judgment or other payment received by the Member to the
extent of the full cost of all benefits provided by AvMed. AvMed's right of reimbursement is
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cumulative with and not exclusive of AvMed's subrogation right and AvMed may choose to exercise
either or both rights of recovery.
14.04 Member and the Member's representatives further agree to:
14.04.01 notify AvMed promptly and in writing when notice is given to any third party of the
intention to investigate or pursue a claim to recover damages or obtain compensation due to
injuries or illness sustained by the Member that may be the legal responsibility of a third
party; and
14.04.02 cooperate with AvMed and do whatever is necessary to secure AvMed's rights of subrogation
and/or reimbursement under this Contract; and
14.04.03 give AvMed a first -priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third party to the extent of the full cost of all
benefits associated with injuries or illness provided by AvMed for which a third party is or
may be responsible (regardless of whether specifically set forth in the recovery, settlement,
judgment or compensation agreement); and
14.04.04 pay, as the first priority, from any recovery, settlement or judgment or other source of
compensation, any and all amounts due AvMed as reimbursement for the full cost of all
benefits associated with injuries or illness provided by AvMed for which a third party is or
may be responsible (regardless of whether specifically set forth in the recovery, settlement,
judgment or compensation agreement), unless otherwise agreed to by AvMed in writing; and
14.04.05 do nothing to prejudice AvMed's rights as set forth above. This includes, but is not limited
to, refraining from making any settlement or recovery, which specifically attempts to reduce
or exclude the full cost of all benefits, provided by AvMed.
14.05 AvMed may recover the full cost of all benefits provided by AvMed under this Contract without regard
to any claim of fault on the part of the Member, whether by comparative negligence or otherwise. No
court costs or attorney fees may be deducted from AvMed's recovery without the prior express written
consent of AvMed. In the event the Member or the Member's representative fails to cooperate with
AvMed, the Member shall be responsible for all benefits paid by AvMed in addition to costs and
attorney's fees incurred by AvMed in obtaining repayment.
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.
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
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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.
15.06 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 Section 9.01.05.
XVI. GRIEVANCE PROCEDURE
Members have the right to a review of any complaint regarding the services or benefits covered under this Plan.
AvMed encourages the informal resolution of complaints. If a Member has a complaint, the Member or someone
he names to act on his behalf (an authorized representative) may call AvMed's Member Services Department,
and a Member Services Representative will try to resolve the complaint over the phone. If the Member asks for
a written response, or if the complaint is related to quality of care, AvMed will respond in writing. The Member
Services Department can also advise Members how to name an authorized representative.
If a Member's complaint cannot be resolved informally (over the telephone), the Member or his authorized
representative may submit the complaint in writing to AvMed. We call this `filing a grievance'. The written
complaint (grievance) will be processed through the formal Member grievance process. The procedures for
filing a grievance are described in 16.02 below.
If a Member has a complaint involving a Claim for benefits, including a benefit denial, he may file an `appeal'
with AvMed. The procedures for filing an appeal are described below, beginning in Section 16.03.
16.01 Grievances relating to Plan services.
16.01.01 A grievance is any complaint other than one that involves a request (Claim) for benefits, or
an appeal of an adverse benefit determination. If a Member's complaint cannot be resolved
informally over the telephone, the complaint may be submitted in writing to AvMed's
Member Services Department. Grievances must be filed within one year of the occurrence of
the event or action that led to the grievance. AvMed will acknowledge and investigate the
grievance, and provide a written response advising of the disposition of the grievance within
60 days after receipt of the grievance. A grievance may be submitted in writing 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
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16.01.02 If not satisfied with AvMed's final decision, Members may contact the Agency for Health
Care Administration (AHCA) or the Department of Financial Services (DFS), in writing,
within 365 days of receipt of AvMed's final decision letter. If a Member appeals AvMed's
decision, the grievance will be reviewed by AHCA's Subscriber Assistance Program (SAP).
The SAP will not hear a grievance that has not completed the entire AvMed grievance
process, nor if the Member has instituted an action pending in State or Federal court.
Members also have the right to contact AHCA or DFS at any time to inform them of an
unresolved grievance. AHCA or DFS may be contacted at:
Subscriber Assistance Program (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
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 for benefits shall be deemed to have been 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 receipt of the Pre -Service Claim. AvMed may
extend this period one time for up to 15 days provided that AvMed determines 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 required to
decide the 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. 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 5 days
following such failure. AvMed's period for making the benefit determination shall be tolled
from the date the notification of the extension is sent to the Claimant, until the date 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 notification of the Adverse Benefit
Determination. AvMed shall notify the Claimant, in accordance with Section 16.08, of its
determination on review within a reasonable period of time, but not later than 30 days after
receipt of the Claimant's request for review of the Adverse Benefit Determination. An
appeal may be submitted to:
AvMed Member Relations
P.O. Box 749
Gainesville, Florida 32602
Telephone: 1-800-882-8633
Fax: (352) 337-8794
16.02.03 If not satisfied with AvMed's final decision, the Member may file a written grievance with
AHCA or DFS within 365 days of receipt of the final decision letter, to request a review of
39
AV-LG-G 100-2010
MP -5523 (10/10)
AvMed's decision by the SAP. The SAP will not hear a grievance that has not completed the
entire AvMed grievance or appeal process, nor if the Member has instituted an action
pending in State or Federal court. Members also have the right to contact AHCA or DFS at
any time to inform them of an unresolved grievance. The addresses for contacting AHCA or
DFS are listed in Section 16.02.02.
16.03 Urgent Care Claims.
16.03.01 Initial Claim. An Urgent Care Claim for benefits, either oral or written, shall be deemed to
have been filed on the date received by AvMed. AvMed shall notify the Claimant of the
benefit determination (whether adverse or not) as soon as possible, taking into account the
medical exigencies, but not later than 72 hours after receipt of 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 receipt of the
Claim, of the specific information required 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:
a) AvMed's receipt of the specified information; or
b) the end of the period afforded the Claimant to provide the specified additional
information.
16.03.02 If the Claimant fails to supply the specified information within the 48 -hour period, the Claim
shall be denied. AvMed may notify the Claimant of the benefit determination orally or in
writing. If the notification is provided orally, a written or electronic notification meeting the
requirements of Section 16.07 shall be provided to the Claimant no later than three days after
the oral notification.
16.03.03
Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent
Care Claim within 180 days of receiving notification of the Adverse Benefit Determination.
AvMed shall notify the Claimant in accordance with Section 16.08, of AvMed's benefit
determination on review as soon as possible, taking into account the medical exigencies, but
not later than 72 hours after receipt of the Claimant's request for review of the Adverse
Benefit Determination. The address for submitting an appeal to AvMed is listed in Section
16.03.02.
16.03.04 If not satisfied with AvMed's final decision, the Member may file a written grievance with
AHCA or DFS within 365 days of receipt of the final decision letter, to request a review of
AvMed's decision by the SAP. The SAP will not hear a grievance that has not completed the
entire AvMed grievance or appeal process, nor if the Member has instituted an action
pending in State or Federal court. Members also have the right to contact AHCA or DFS at
any time to inform them of an unresolved grievance. The addresses for contacting AHCA or
DFS are listed in Section 16.02.02.
16.04 Concurrent Care Claims
16.04.01
Any reduction or termination of Concurrent Care by AvMed (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 16.07, 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
AV-LG-G 100-2010
MP -5523 (10/10)
40
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 a course of treatment beyond a previously approved
period of time or number of treatments with respect 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 receipt of 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 a course of
treatment, whether involving an Urgent Care Claim or not, shall be made in accordance with
Sections 16.06 through 16.08.
16.05 Post -Service Claims.
16.05.01 Initial Claim. A Post -Service Claim for benefits shall be deemed to have been filed on the
date received by AvMed. AvMed shall notify the Claimant in accordance with Section
16.07, of the benefit determination within a reasonable period of time, but not later than 30
days after receipt of the Post -Service Claim. AvMed may extend this period one time for up
to 15 days, provided that AvMed determines 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 the
notification of the extension is sent to the Claimant, until the date 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.
16.05.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Post -
Service Claim within 180 days of receiving notification of the Adverse Benefit
Determination. AvMed shall notify the Claimant in accordance with Section 16.08, of
AvMed's determination on review within a reasonable period of time, but not later than 60
days after receipt of the Claimant's request for review of the Adverse Benefit Determination.
An appeal may be submitted to AvMed Member Relations, at the address listed in Section
16.03.02.
16.05.03 If not satisfied with AvMed's final decision, the Member may file a written grievance with
AHCA or DFS within 365 days of receipt of the final decision letter, to request a review of
AvMed's decision by the SAP. The SAP will not hear a grievance that has not completed the
entire AvMed grievance or appeal process, nor if the Member has instituted an action
pending in State or Federal court. Members also have the right to contact AHCA or DFS at
any time to inform them of an unresolved grievance. The addresses for contacting AHCA or
DFS are listed in Section 16.02.02.
16.06 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:
16.06.01 The specific reasons for the Adverse Benefit Determination.
16.06.02 Reference to the specific Plan provisions on which the determination is based.
41
AV-LG-G 100-2010
MP -5523 (10/10)
16.06.03 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.
16.06.04 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.
16.06.05 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.
16.06.06 If the Adverse Benefit Determination is based on whether the treatment or service is
experimental and/or investigational or not Medically Necessary, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to the
Claimant's medical circumstances, or a statement that such explanation shall be provided
free of charge upon request.
16.06.07 In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a
description of the expedited review process applicable to such Claim.
16.07 Review procedure upon appeal. AvMed's appeal procedures shall include the following substantive
procedures and safeguards:
16.07.01 Claimant may submit written comments, documents, records and other information relating
to the Claim.
16.07.02 Upon request and free of charge, the Claimant shall have reasonable access to and copies of
any Relevant Documents.
16.07.03 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.
16.07.04 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.
16.07.05 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, medication, 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.
16.07.06 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.
16.07.07 The appeal shall provide that the Health Professional engaged for purposes of a consultation
in Section 16.07.05 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.
42
AV-LG-G 100-2010
MP -5523 (10/10)
16.07.08 In the case of an Urgent Care Claim, there shall be an expedited review process pursuant to
which:
a) Request for an expedited appeal of an Adverse Benefit Determination may be submitted
orally or in writing by the Claimant; and
b) 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.
16.08 Manner and content of appeal notification. AvMed shall provide a Claimant with written or electronic
notification of AvMed's benefit determination upon review.
16.08.01 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.
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 Documents.
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 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.
17.02 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.
17.03 Certificate of Coverage. AvMed shall provide a copy of the Certificate of Coverage for each Subscriber.
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.
17.04 Circumstances not reasonably within the control of AvMed. In the event of circumstances not
reasonably within the control of AvMed, including major disasters and under such circumstances as
43
AV-LG-G 100-2010
MP -5523 (10/10)
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.
17.05 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.
17.06 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. Subscribing Group hereby represents that it has met the non-discrimination
testing requirements under Code Sec. 105(h). 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.
17.07 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.
17.08 Entirety of Contract. This Agreement and all applicable schedules, exhibits, riders, amendments 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.
17.09 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.
17.10 Gender. Whenever used, the singular shall include the plural and the plural the singular and the use of
any gender shall include all genders.
17.11 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.
17.12 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
44
AV-LG-G 100-2010
MP -5523 (10/10)
containing any false, incomplete or misleading information is guilty of a felony, punishable as provided
by the Florida Statutes.
17.13 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.
17.14 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: 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.
17.15 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.
17.16 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.
17.17 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.
17.18 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.
17.19 Waiver. A Claim that has not been timely filed with AvMed within one year of date of service shall be
considered waived.
45
AV-LG-G 100-2010
MP -5523 (10/10)
Contract Number(s):
Subscribing Group Name:
Effective Date:
Group Contract
AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application
109330
Village Of Key Biscayne
05/01/11
This Group Contract provides the benefits listed below:
Identifier
AV-LG-15/250/1500/10%-10
AV-Deductible/Co-insurance Amendment -10
AV-LG-RX-3x-15/30/50/75/50 %-10
AV -G 100-M H P H-10
AV-GI00-SAP H-10
AV -VISION -R-99
AV -DP -12-R-02
AV -G 100-ETP-R-97
Eligibility
Description
Summary of Benefits
Ded & Co -ins
Prescription Drug
IP Mental Health
Substance Abuse
Vision
Domestic Partner
ETOP
HEALTH PLANS
Active Employees (Class 1) are required to work 30 hours per week to become eligible for coverage under this Contract.
Employees will become eligible for coverage on the first of the month following 30 days of employment.
Active Employees (Class 2) are required to work 30 hours per week to become eligible for coverage under this Contract.
Employees will become eligible for coverage on the first of the month following 30 days of employment.
Termination
For Active Employees (Class 1), termination of coverage under this Contract shall become effective Termination Date.
For Active Employees (Class 2), termination of coverage under this Contract shall become effective End of Month.
Monthly Membership Charges
Subscriber Only
Subscriber plus Spouse
Subscriber plus One Dependent (No Spouse)
Subscriber plus Two or More Dependents
Subscriber plus Spouse and One or More Dependents
$441.94
$883.89
$883.89
$1,193.29
$1,193.29
AV -Master Application -07
MP -2027 (1/07)
AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
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, 2011 and may be renewed annually, not later than the anniversary date, upon
mutual agreement of the parties. This Contract period begins at 12:01 a.m. Eastern Standard Time on the effective date or
on the anniversary date, if a renewal. The 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, 2011. Subsequent payments are due on the 1st 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.
The provisions contained in the Schedule of Benefits 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, 2011.
Subscribing Group:
Village Of Key Biscayne AVMED, Inc. d/b/a AVMED Health Plans
By:
,,(2.-C,
J AJ ( (- r / L r#.t'
Date:
By:
Signature
Patricia Nelson
Name Name
e.- -iti 0ff(Qrt k4 het
Title 7
? - /3_ ow/
Director of Client Services
Date:
Title
AV -Master Application -07
MP -2027 (1/07)
LARGE GROUP
$15/$250/$1,500/10%
Benefit Summary
SCHEDULE OF BENEFITS
AvMw
HEALTH PLANS
COST TO MEMBER
DEDUCTIBLE
PER CALENDAR YEAR
INDIVIDUAL / FAMILY
The Deductible does not apply toward the Out -of -Pocket Maximum
$250 / $750 annually
OUT-OF-POCKET MAXIMUM
INDIVIDUAL / FAMILY per Calendar Year
The Out -of -Pocket Maximum includes Co payments and Co-
insurance amounts unless otherwise excluded
$1,500 / $3,000 annually
PREVENTIVE CARE
NOT SUBJECT TO DEDUCTIBLE
Preventive care services include, but are not limited to:
• Well -woman examinations, including Pap smears
• Annual physical examinations
• Immunizations
• Well -child care and immunizations, including routine vision
and hearing screenings by a pediatrician for children under 18
• Screening mammograms
• Colorectal cancer screening, including colonoscopies
• HIV screening
NO CHARGE
AVMED PRIMARY CARE
PHYSICIAN
Services at Participating Primary Care Physicians' offices include,
but are not limited to:
• Office visits
• Maternity -outpatient visits
• Diagnostic imaging, laboratory or other diagnostic services
• Minor surgical procedures
$15 per visit
MATERNITY CARE • Initial visit
• Subsequent visits
$15 Co -payment
NO CHARGE
AVMED SPECIALTY HEALTH
CARE PHYSICIAN
• Office visits
Additional charges will apply if Outpatient Diagnostic Tests are
performed in the Specialist's office.
$25 per visit
HOSPITAL 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
$250 per admission; 100%
coverage thereafter
OUTPATIENT SERVICES
• Outpatient surgeries, including cardiac catheterizations and
angioplasty
• Outpatient therapeutic services, including:
o Drug infusion therapy
$250 Co -payment
$100 Co -payment
o Injectable drugs (Charges for injectable drug waived if $75 Co -payment
incidental to same -day chemotherapy infusion/treatment)
OUTPATIENT DIAGNOSTIC
• Complex diagnostic imaging, including but not limited to CAT 10% of the contracted rate,
TESTS Scan, PET Scan, MRI after Deductible
• Other non -preventive diagnostic imaging tests
Charges for office visits will also apply if services are performed
in a Specialist's office
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 or 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.
$100 Co -payment
AV-LG-15/250/1500/10%-10
MP -5227 (10/10)
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 participating retail clinic
• Medical Services at a non -participating urgent/immediate care
facility or non -participating retail clinic
$40 Co -payment
$15 per visit
$60 Co -payment
AMBULANCE • 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
$100 Co -payment
FAMILY PLANNING • Voluntary family planning services
• Sterilization (In addition to any Outpatient Facility charge)
$15 per visit
$250 Co -payment
ALLERGY TREATMENTS
• Injections
• Skin testing
$15 per visit
$50 per course of testing
PHYSICAL, SPEECH AND • Short-term physical, speech or occupational therapy for acute
OCCUPATIONAL THERAPIES conditions
Coverage is limited to 30 visits per Calendar Year for all
services combined.
$15 per visit
DIAGNOSIS AND TREATMENT
OF AUTISM SPECTRUM
DISORDER
• Applied Behavior Analysis services
• Physical, speech or occupational therapy for the treatment of
Autism Spectrum Disorder
Coverage for all services related to Autism Spectrum Disorder is
limited to $36,000 annually and may not exceed $200,000 in total
benefits.
$25 per visit
$15 per visit
SKILLED NURSING FACILITIES • Up to 20 days post -hospitalization care per Calendar Year when 10% of the contracted rate,
AND REHABILITATION prescribed by physician and authorized by AvMed. after Deductible
CENTERS
CARDIAC REHABILITATION
• Cardiac rehabilitation is covered for the following conditions: $15 per visit
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 Calendar Year.
HOME HEALTH CARE • Limited to 60 skilled visits per Calendar Year 10% of the contracted rate,
after Deductible
DURABLE MEDICAL
EQUIPMENT AND ORTHOTIC
APPLIANCES
Equipment includes: 10% of the contracted rate,
• Hospital beds, walkers, crutches and wheelchairs after Deductible
Orthotic appliances are limited to: Benefits limited to $2,000 per
• Leg, arm, back and neck custom-made braces Calendar Year
PROSTHETIC DEVICES Prosthetic devices are limited to: 10% of the contracted rate,
• Artificial limbs, artificial joints and ocular prostheses after Deductible
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 consult your AvMed Group Medical and Hospital Service Contract.
PLEASE NOTE: This benefit plan will be administered in accordance with the requirements of Health Care Reform.
AV-LG-15/250/1500/10%-10
MP -5227 (10/10)
Amendment
Large Group - Deductible and Co-insurance
AvMED
HEALTH PLANS
These provisions of the policy are amended as follows:
Part III. DEFINITIONS, has been amended to add the following definitions:
• "Calendar Year" means the twelve-month period beginning January 1 and ending December 31.
• "Co-insurance" means the amount a covered Member must pay, once the Deductible has been met, and is
expressed as a percentage of the allowed amount for the covered benefit.
• "Deductible" means the first payments up to a specified dollar amount, excluding Co -payments, that a
Member must make in the applicable Calendar Year for covered benefits. The Deductible applies to each
Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the
Deductible, "family" means the Subscriber and Covered Dependents. The Deductible must be satisfied once
each Calendar Year, except for:
o the Common Accident Provision: if the Deductible applies to accident expenses and if 2 or more
Members of any family receive covered benefits because of disabilities resulting from injuries
sustained in any one accident, the Deductible will be applied only once with respect to all covered
benefits received as a result of the accident.
o the Deductible Credit Provision: any expense incurred by a Member while covered under the
group's prior carrier will be credited toward satisfaction of the Deductible under this Plan if:
o the expenses were incurred during the 90 -day period before the effective date of the Group
Plan;
o the expenses were applied toward satisfaction of the Deductible under the prior coverage
during the 90 -day period before the effective date of this Group Plan; and
o the expenses would be considered eligible expenses under this Group Plan.
However, in order to receive credit, you must supply evidence of satisfaction of the Deductible
under the prior coverage by providing AvMed Health Plans written proof of what has been paid by
prior carrier.
o the Carryover Provision: if any part or all of the Deductible has been satisfied during the last 3
months of the preceding Calendar Year, the Deductible for the next Calendar year will be reduced
by the amount satisfied.
Under Part VII. MONTHLY PAYMENTS AND CO -PAYMENTS, has been amended as follows:
7.03 Annual Maximum Out -of -Pocket Limits (as described in your Schedule of Benefits). Co-insurance and Co -payments
you pay for benefits received during any Calendar Year are accumulated toward your annual maximum out-of-pocket
limit. Once you meet your individual or family annual maximum out-of-pocket limit in any Calendar Year, AvMed will
pay 100% of the allowable charges for all covered services for the remainder of that Calendar Year. Expenses that do
not count toward the annual maximum out-of-pocket limit are expenses used to satisfy the individual or family
Deductible and any services provided under the Prescription Drug, Mental Health, Substance Abuse, Vision and other
supplemental riders.
7.04 Member shall pay premiums, applicable supplemental charges, Deductibles, Co -payments and/or Co-insurance as
provided in this Contract. If the Member fails to do so, upon ten (10) 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.
7.07 A Member will be entitled to covered benefits after the Member has satisfied the Deductible amount, if any, specified on
the Schedule of Benefits. After satisfying the Deductible, the Member must pay any applicable Co-insurance for
covered benefits. Covered benefits to which the Deductible applies are shown in the Schedule of Benefits. The
Deductible does not apply to certain covered benefits. In those instances, the Member must pay any applicable Co -
payments for covered benefits to which the Deductible does not apply.
AV-Deductible/Co-insurance Amendment -09
MP -3647 (10/09)
Prescription Medication Benefits
$15/30/50/75/50% CO -PAYMENT with Contraceptives
HEALTH PLANS
DEFINITIONS
Brand medication means a Prescription Medication that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer or a
medication that is identified as a Brand medication by AvMed. AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits Manager.
Brand Additional Charge means the additional charge that must be paid if you or your physician choose a Brand medication when a Generic equivalent is
available. The charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to the Non -
Preferred Brand Co -payment.
Cost -sharing Medications are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively minor
non -life threatening conditions or which have multiple generic or non-prescription therapeutic alternatives. Such medications are subject to Co-insurance and
coverage is limited as outlined below.
Dental -specific Medication is medication used for dental -specific purposes, including but not limited to fluoride medications and medications packaged and
labeled for dental -specific purposes.
Formulary List means the listing of preferred and non -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.
Generic medication means a medication that has the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's
Pharmacy Benefits Manager.
Maintenance Medication is a medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed one
year.
Participating Pharmacy means a pharmacy (retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide Prescription
Medications to AvMed Members and has been designated by AvMed as a Participating Pharmacy.
Prescription Medication 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.
Prior Authorization means the process of obtaining approval for certain Prescription Medications (prior to dispensing) according to AvMed's guidelines. The
prescribing physician must obtain approval from AvMed. The list of Prescription Medications requiring Prior Authorization is subject to periodic review and
modification by AvMed. A copy of the list of medications requiring Prior Authorization and the applicable criteria are available from Member Services or from
the AvMed website.
Specialty Medications are high cost medications that are self-administered by members. These medications may be limited in distribution to participating
specialty pharmacies and Prior Authorization is often required.
HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK?
To obtain your Prescription Medication, take your prescription to, or have your physician call, an AvMed Participating Pharmacy. Your physician should
submit prescriptions for Specialty Medications 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 Preferred Generic Medications: $ 15.00 Co -payment
Tier 2 Preferred Brand Medications: $ 30.00 Co -payment
Tier 3 Non -Preferred Brand or Generic Medications: $ 50.00 Co -payment
Tier 4 Specialty Medications: $ 75.00 Co -payment
Tier 5 Cost -sharing Medications: 50% Co -Insurance
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 Preferred Generic Medications: $ 45.00 Co -payment
Tier 2 Preferred Brand Medications: $ 90.00 Co -payment
Tier 3 Non -Preferred Brand or Generic Medications: $ 150.00 Co -payment
Tier 4 Specialty Medications are not available through mail service
Tier 5 Cost -sharing Medications are not available through mail service
AV-LG-RX-3 x -15/30/50/75/50%a-10
MP -3450 (10/10)
Prescription Medication Benefits, continued
WHAT IS COVERED?
• Your Prescription Medication coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by your
AvMed physician in accordance with AvMed's coverage criteria. 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.
• Your Prescription Medication coverage may require Prior Authorization, including the Progressive Medication Program, for certain covered medications.
The Progressive Medication Program encourages the use of therapeutically -equivalent lower -cost medications by requiring certain medications to be
utilized to treat a medical condition prior to approving another medication for that condition. This includes the first -line use of preferred medications that
are proven to be safe and effective for a given condition and can provide the same health benefit as more expensive non -preferred medications at a lower
cost.
• Your retail Prescription Medication 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 and subject to a maximum of 13 refills per year. 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, Prior Authorization may be required for covered medications.
• Your mail-order Prescription Medication 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 Specialty Medication coverage extends to many injectable and high cost oral medications approved by the FDA. These medications must be
prescribed by a physician and dispensed by a participating specialty pharmacy. The Co -payment levels for Specialty Medications apply regardless of
provider. This means that you may be responsible for the appropriate Co -payment whether you receive your Specialty Medication from the pharmacy, at
the physician's office or during home health visits. Specialty Medications are limited to a 30 -day supply.
• Your Prescription Medication 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 experience 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
• Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative is available, unless otherwise
indicated on AvMed's Formulary List.
• Medications not included on AvMed's Formulary List.
• Medical supplies, including therapeutic devices, dressings, appliances and support garments
• Replacement Prescription Medication products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill
• Diaphragms and other contraceptive devices
• Fertility Medications
• Medications or devices for the diagnosis or treatment of sexual dysfunction
• Dental -specific Medications for dental purposes, including fluoride medications
• Prescription and non-prescription 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 Medications (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-prescription 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 Prior 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-LG-RX-3 x-15/30/50/75/50%-10
MP -3450 (10/10)
Amendment
AvMi
HEALTH PLANS
Prescription Medication Benefits
As of the effective date, the Prescription Medication Benefit Amendment is modified by the addition of the
following:
AvMed covers the following Generic preventive medications at no cost, with a written prescription from a
member's treating physician and when filled at a participating retail pharmacy (excludes mail-order and specialty
pharmacies):
• Aspirin 80 to 325 mg once a day, when prescribed for men 45-79 years of age, or women 55-79 years of age;
• Folic Acid 0.4 to 0.8 mg once a day, when prescribed for women 15-50 years of age. Prior authorization is
required if prescribed for women below the age of 15 or above the age of 50;
• Iron supplements, when prescribed for infants through 12 months of age;
• Fluoride supplements, when prescribed for children below 18 years of age. Prior authorization is required.
NOTE: These benefits will be administered in accordance with the requirements of Health Care Reform
AV-LG-Rx-Prev-10
MP -5536 (10/10)
AvMiii
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)
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 Eligibility will be added for a Domestic Partner and his or her children.
Definition of Domestic Partner:
A Domestic Partner means an unmarried adult who:
• Cohabits with you in an emotionally committed and affectional relationship that is meant to be of
lasting duration;
• Is not related by blood or marriage;
• Is at least eighteen years of age;
• Is mentally competent to consent to a contract;
• Has filed a Domestic Partnership agreement or registration with the Employer, if available, in the state
(and/or city) of residence;
• Has shared financial obligations including basic living expenses for the twelve month 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)
AvMn
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 -G 100-ETP-R-97
MP -1321 (1/04)
Amendment
Mental Health Services
AvMa
HEALTH PLANS
As of the effective date, outpatient and inpatient mental health services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
• Office visits for mental health services are covered subject to the Member's cost sharing
responsibility for primary care services.
■ Inpatient or partial hospitalization for mental health services is covered when a Member is
admitted to a Participating Hospital or Health Care Facility. Coverage is subject to the Member's
cost sharing responsibility for inpatient Hospital Services.
• All other outpatient mental health services are covered at NO CHARGE.
Residential treatment services are not covered and are specifically excluded from benefits provided under
this Amendment.
Prior authorization is required for mental health services. Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact AvMed at 1-800-882-8633.
AV-G100-MHPH-10
MP -5296 (10/10)
Amendment
Substance Abuse Services
AvMED
HEALTH PLANS
As of the effective date, outpatient and inpatient substance abuse services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
• Office visits for substance abuse services are covered subject to the Member's cost sharing
responsibility for primary care services.
■ Inpatient or partial hospitalization for substance abuse services is covered when a Member is
admitted to a Participating Hospital or Health Care Facility. Coverage is subject to the Member's
cost sharing responsibility for inpatient Hospital Services.
• All other outpatient substance abuse services are covered at NO CHARGE.
Residential treatment services are not covered and are specifically excluded from benefits provided under
this Amendment.
Prior authorization is required for substance abuse services. Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact AvMed at 1-800-882-8633.
AV -G 100-SAPH-10
MP -5298 (10/10)