HomeMy WebLinkAboutReso 98-109
RESOLUTION NO. 98- \ o~
A RESOLUTION OF THE CITY COMMISSION OF THE
CITY OF SUNNY ISLES BEACH, FLORIDA, APPROVING
AN AGREEMENT WITH FLORIDA MUNICIPAL
INSURANCE TRUST, ATTACHED HERETO AS EXHIBIT
"A"; AUTHORIZING THE CITY MANAGER TO EXECUTE
SAME; PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City Manager and the Finance Director have negotiated with several
insurance companies for employee health insurance; and
WHEREAS, the premiums quoted by Florida Municipal Insurance Trust for this coverage
are less than the City now pays for employees' health insurance;
NOW THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE CITY
OF SUNNY ISLES BEACH, FLORIDA, AS FOLLOWS:
1. The City Commission hereby approves the agreement with Florida Municipal Insurance
Trust for employee health insurance, attached hereto as Exhibit "A".
2. The City Manager be and is hereby authorized to execute the attached agreement.
3. This Resolution shall become effective upon adoption.
PASSED AND ADOPTED this 17th day of December, 1998.
ATTEST:
~~~-
. chard Brown:Morilla, City Clerk
APPROVEU AS TO FORM:
.~.. -""I ,
Health Insurance Res.
-1-
AND LEGAL SUFFICIENCY:
Vote: 5'-0
Mayor Samson
Vice Mayor Turetsky
Commissioner Iglesias
Commissioner Kauffinan
Commissioner Morrow
Heilth Insurance Res.
~Yes)
~Y es)
t7(Yes)
~(Y es)
(Yes)
Moved by: ~\- ~
Seconded by: ~~.l-.: '
_(No)
_(No)
_(No)
_(No)
_(No)
-2-
~
...-...
llorida
Municipal
INSURANCE
TRUST
FLORIDA LEAGUE OF CITIES
CERTIFICATE OF COVERAGE
MEDICAL PLAN OF BENEFITS
florida Municipal Insurance Trust
Certificate of Coverage
This Certificate of Coverage and Medical Master Plan of' Benefits
("Certificate") sets forth your rights and obligations as a participant. It is
important that you READ YOUR CERTIFICATE CAREFULLY and familiarize
yourself with its terms and conditions.
The Plan may require that the participant contribute to the required
premiums. Information regarding the premium and any portion of the
premium cost a participant must pay can be obtained from your employer.
Florida Municipal Insurance Trust ("Trust") agrees with your employer to
provide coverage for medical services, subject to the terms, conditions,
exclusions and limitations of the plan. The plan is issued on the basis of
the Participation Agreement of the employer and payment of the required
plan charges. The employer's application is made a part of the contract.
The Trust shall not be deemed or construed as an employer for any purpose
with respect to the administration or provision of benefits under the
employer's benefit plan. The Trust shall not be responsible for fulfilling
any duties or obligations of an employer with respect to the employer's
benefit plan.
The Trust has sole and exclusive discretion in interpreting the benefits
covered under the plan and the other terms, conditions, limitations and
exclusions set out in the plan and in making factual determinations related
to the plan and its benefits. The Trust may, from time to time, delegate
discretionary authority to other persons or entities providing services in
regard to the plan.
The Trust reserves the right to change, interpret, modify, withdraw or add
benefits or terminate the policy, in its sole discretion, without prior notice
to or approval by participants. No person or entity has any authority to
make any oral changes or amendments to the policy.
Please show your plan identification card each time you request health care
services. This is to ensure that the providers know that you are part of the
plan; otherwise you may receive a bill for health care services.
This plan shall take effect on the date specified and will be continued in
force by the timely payment of the required plan charges when due, subject
to termination of the plan as provided. All coverage under the plan shall
begin at 12:01. a.m. and end at 12:00 midnight Eastern time.
Section
I.
II.
Ill.
IV.
v.
VI.
vu.
VUI.
IX.
X.
Xl.
XlI.
XlII.
XIV..
XV.
XVI.
XVII.
XVIll.
XIX.
XX.
XXI.
Rortda Municipal Insurance Trust
Medical Master Plan of Benefits
TABLE OF CONTENTS
Heading
~
I>~JrIIfI1rI()IfS----------------------------------------------------------------- 1
I>~I>1J~1rIIl~~ ______________________________________________________--------- Ei
~IJrE1'IM~ MAXIMUM AND RES1r()RA1rI()N ()Jr II~N~JrI1'S--------- Ei
MAXIMUM EXPENSE 1r() PAR1rI~IPAN1rS ______________________________ 7
~~IGIIII~I1rY AND ENR()~~MEN1r.---------------------------------------- 7
~()V~RED EXPENS~ _____________________________________________________12
H()SPI1r AL IIILL SELJr -AUDI1r ____________________________________________19
~X~~USI()NS AND LIMI1r A1rI()NS _______________________________________ 20
~()()RDINA 1r1()N ()Jr IIENEFITS _________________________________________ 23
PRE-~XlS1rING ~()NDITI()NS LIMI1rATI()NS _________________________24
1rIM~ ()Jr PAYMENT, GRA~E PERI()D----------------------------------25
~()IfI>I1rI()NS Jr()R RENDERING SERVICE ____________________________ 25
~MPLOYER'S TERMINATI()N AND RENEWAL _______________________ 2Ei
P AR1rI~IP AN1r'S TERMINA TI()N ()Jr ~()VERAGE -------------------- 2Ei
~()If1rlNUATI()N ()Jr ~()VERAGE - ~()IIRA ____________________________28
PRES~RlP1'I()N DRUGS ___________________________________________________ 30
G EIf~RAL PR()VlSIONS ___________________________________________________ 31
PAYMEN1r ()Jr IIENEJrITS, ASSIGNMEN1r ______________________________33
GRI~V ANCE PRO~EDURES ______________________________________________ 33
SlJIIR()GA1rI()N--------------------------------------------__________________33
1f()1rICE _______________________________________________________________________34
florida Municipal Insurance Trust
Medical Malter Plan of Benefits
SECTION I - DEFINITIONS
Accident means a non-occupational, unforeseeable, unintentional and unplanned
event resulting in a traumatic injury to a participant occurring while this Plan is
in force and resulting directly and independently of all other causes in loss
covered by this Plan. The acts of bending, stooping, lifting, stretching or standing
are covered as a sickness as defmed herein.
Active Employee means an eligible employee who is performing all of his or her
regular duties on a full-time basis for the Employer on a regularly scheduled work
day.
Benefits or Coverages means those hospital, medical, surgical and authorized
related expenses as hereinafter provided, for which payment shall be made to, or
on behalf of, a participant.
Birthing: Center means a state-licensed facility or institution equipped to provide and
provides prenatal care, delivery, immediate postpartum care of a child at the
facility, has a physician or Certified Nurse Midwife present at all births and
immediate postpartum period, provides full-time nursing services directed by a
Registered Nurse or Certified Nurse Midwife, and keeps medical records on each
patient and child. A birthing center is not an ambulatory surgical facility or a
hospital.
Calendar Year means a period of twelve (12) consecutive months commencing on
January 1 and ending on December 31 in any given year. For participants
enrolling during a calendar year, the Calendar Year begins on the effective date of
their enrollment and ends on December 31 of that same year.
Certified Nurse Midwife means a person who is licensed by the state as an advanced
Registered Nurse Practitioner under Ch. 464, F.S., and who is certified to practice
midwifery by the American College of Nurse Midwives.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985 (H.R.
3128) signed into law on April 17, 1986 as Public Law 99-272, as amended.
Co-Pay means the charge that the participant is required to pay for certain..covered
. expenses provided under the Plan. This may be defined as either a dollar amount
or a percentage of covered expenses. The participant is responsible for the
payment of any Co-Pay directly to the Service Provider at the time of service.
Contract means this agreement between the Trust and the employer by virtue of
which the employer and its eligible employees and their dependents become
participants; the Participation Agreement of the employer; The Agreement and
Declaration of Trust creating the Health Benefit Trust; the rules, regulations and
resolutions adopted by the Board of Trustees; the attached endorsements and
riders, if any; the individual applications of the employees; and the identification
cards issued to employees indicating their participation in the coverage provided
hereunder.
Covered Expenses means those eligible servlces as outlined in Section VI of this
Plan.
Dependent means the legal, married spouse of an employee and/ or eligible legal,
unmarried (never married) dependent children as hereinafter described, residing
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
in the United States and its territories.
A child is a dependent if the child meets the following conditions:
(1) the child is a natural child, stepchild, legally adopted child, or a child
who has been placed under the legal court-ordered guardianship of the
participant, and
(2) the child is in the custody of and financially dependent upon the
participant. (This is waived if the participant is required to provide
coverage to the child due to court order or divorce decree.)
A newborn child of a participant having dependent coverage is entitled to the
same benefits as the participant; provided, however, a dependent child shall not
be entitled to maternity benefits under this Plan. A newborn child of a dependent
child covered under the Plan shall terminate 18 months after the birth of the
newborn child.
A dependent child shall cease to be a participant at the end of the calendar year
in which such child reaches age 19. However, if such child is in full-time
attendance at an accredited school, college, or university and is dependent upon
the participant for support, coverage will continue until the end of the calendar
year in which the child reaches age 25, or upon the marriage of such child,
whichever event shall first occur. Full-time attendance means that the student is
enrolled for the number of hours which is considered to be a full-time attendance
by the institution the student is attending. Satisfactory proof of such attendance
shall be furnished to the Trust upon request.
A dependent child, regardless of age, shall continue to be covered under this Plan
while the child is and continues to be:
(1) incapable of self-sustaining employment by reason of mental retardation
or physical handicap; and
(2) chiefly dependent upon the employee for support and maintenance;
provided such condition occurred while such dependent was covered
under this Plan. Satisfactory proof of such continuing incapacity and
dependency must be furnished to the Trust.
(3) The burden is on the participant to establish such dependent meets or
continues to meet the criteria specified in (1) and (2).
Durable Medical Equipment means medical equipment designated for repeated use
and which is medically necessary to improve the functioning of a malformed body
member, or to prevent further deterioration of the patient's medical condition.
EmDloyee means an officer or employee of the employer or any class or classes of
such employees, regularly working thirty (30)** or more hours a week, who is
eligible for coverage hereunder ~ who has been so designated by the employer and
who holds a valid Social Security Number. This definition shall include elected
officials of the employer and employees who have retired and are receiving
retirement benefits pursuant to a retirement plan lawfully established and
maintained qy the employer.
Emplover means each and every county, municipality, school board, special taxing
district or local governmental unit established within, and pursuant to the laws
of, the State of Florida and which becomes a party to this Trust by executing a
-=
Ronda Munlclpallnsurlnce Trust
Medical Master Plan of Beneflts
Participation Agreement, and who has agreed to be bound by all the terms and
provisions of the Trust Agreement, the Participation Agreement and the rules and
regulations adopted by the Trustees in the administration of the Trust.
HIV infection or a sDecific sickness or medical condition derived from such
infection means the human immunodeficiency virus identified as the causative
agent of acquired immune deficiency syndrome, Acquired Immune Deficiency
Syndrome, an acquired immune deficiency syndrome-related complex, or a
specific sickness or medical condition derived from such infection.
Home Health Agency means any state licensed public agency or private organization
that is equipped to provide and provides home health services.
Home Health Services means any or all of the following health and medical ~ervices
and medical supplies when furnished to an individual by a home health agency in
a place of residence used as a participant's home:
(1) part-time or intermittent nursing care provided by a Registered Graduate
Nurse or a Licensed Practical Nurse;
(2) physical, occupational, or speech therapy;
(3) medical social services, home health aid servIces, and nutritional
guidance;
(4) medical supplies, other than drugs or biologicals prescribed by a
physician, and the use of medical appliances.
HosDice Care means care given to a terminally ill participant by or under
arrangements with a hospice care agency, and must meet the standards outlined
by the National Hospice Association.
Hos~ice Care Agency means a state licensed organization and which:
(1) has twenty-four (24) hour hospice care available; and
(2) provides skilled nursing services, medical social services, psychological
and dietary counseling; and
(3) provides physician services, physical therapy, part-time home health aide
services and inpatient care; and
(4) keeps medical records; and
(5) has a full-time administrator.
Hospital means an institution which is licensed and operated in accordance with the
laws of the jurisdiction in which it is located pertaining to institutions identified
as hospitals, and which is primarily engaged in furnishing for compensation,
diagnostic and therapeutic facilities for surgical and medical diagnosis, which
provides treatment and care of injured and sick persons by or under the
supervision of a staff of physicians who are duly licensed to practice medicine,
and which continuously provides twenty-four (24) hour a day nursing service by
Registered Graduate Nurses, and which is not, other than incidentally, a
sanitarium, nursing home, place for rest, place for the aged, place for drug addicts
or place for alcoholics. "Hospital" also means:
(1) an institution which is an "ambulatory surgical center", as defined and.
licensed under Florida Statutes, or
.
(2) a "Psychiatric Hospital" which is an institution legally constituted and
.. Unless otherMse stated In the Schedule of Benefits (7/98)
Page 3
Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
licensed as a psychiatric hospital and properly accredited to provide
psychiatric, diagnostic and therapeutic services for the treatment of
patients who have mental illnesses.
Hospital Service means and includes receiving a participant into a hospital for
services set forth in this Plan and outlined on the hospital bill and subject to the
rules and regulations of the hospital, for and during such time only as the
participant is necessarily treated on an inpatient or outpatient basis in the
hospital, under the treatment and care of a physician for any conditions covered
hereunder.
Inpatient means a patient who has been admitted upon order of a physician as a bed
patient for treatment in a hospital for at least six (6) continuous hours.
Lifetime Maximum means the maximum liability of the Trust subject to the benefits
provided in this Plan, with respect to each participant covered under this Plan,
during the entire period such participant is covered hereunder.
Massage Therapist means a person properly licensed to administer massages,
pursuant to Chapter 480 of the Florida Statutes, or other states' applicable law.
Medically Necessary means treatment, care or services that are consistent with the
diagnosis, complies with acceptable medical standards, is not primarily for the
participant's convenience and is the most appropriate level of service which can
be safely provided. When applied to hospital inpatient care, it means that care
cannot be safely provided on an outpatient basis. Care that has not received
federal approval will not be considered medically necessary.
Midwife means any person, other than a licensed physician or Certified Nurse
Midwife, who is state licensed to practice midwifery.
Midwifery means the practice of supervising the conduct of a normal labor and
childbirth, with the informed consent of the parent; the practice of advising the
parents as to the progress of childbirth; and the practice of rendering prenatal
and postnatal care.
New Employee means an employee who has never been previously employed by the
employer prior to the effective date of this Plan and who is employed by the
employer on or after the effective date of this Plan, or an employee who was
employed by the employer prior to the effective date of this Plan and was ineligible
to participate in the employer's prior plan because the employee had not
completed the period of continuous employment with the employer as set forth in
such plan, if any, to qualify to participate in such plan.
Occupational Therapist means a person who is duly registered or licensed by the
state in which such person is engaged in the practice of occupational therapy and
who is a member of the American Occupational Therapy Association.
Outpatient means 'a patient who has not been admitted to a hospital as an inpatient
and who has not been charged for room and board.
Participant means and includes the employee and any of his or her legal dependents
covered under this Plan. Participant also means and includes those employees
and their dependents that qualify for continuation of coverage under COBRA.
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
Physical Therapist means a person who is duly registered or licensed by the state in
which such person is engaged in the practice of physical therapy and who is a
member of the American Physical Therapist's Association.
Physical Therapy means the diagnosis, treatment, prevention, or rehabilitation of
any injury, disease, or other health condition, including the use of apparatus and
equipment directly related thereto, by the use of physical, chemical, and other
properties of air; electricity; exercise; massage; radiant energy,' including
ultraviolet, visible or infrared rays; ultrasound; or water; or by the use of
acupuncture or tests of neuromuscular functions; provided such diagnosis,
treatment, prevention, or rehabilitation is performed pursuant to minimum
criteria and standards of practice established by a statutorily created board that
primarily consists of physical therapists and/ or physicians and pursuant to a
written plan of treatment prescribed and approved by a physician.
Physician means a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) legally
qualified to practice medicine and perform surgery at the time and place the
service is rendered. For services covered under this Plan, doctors of dental
surgery (D.D.S.), doctors of podiatry (D.P.M,), and doctors of chiropractic (D.C.),
when acting within the scope of their licenses, are deemed to be physicians.
Plan means this Master Plan of Benefits, including any Schedule of Benefits attached
hereto.
Pre-existing Condition means any condition, physical or mental, for which medical
advice, diagnosis, care or treatment was recommended or received within the
twelve (12) month period ending on the enrollment date.
Preventative Care means services and supplies ordered and/ or provided by or under
the direction of a physician for which there is no medical diagnosis or does not
seek to diagnose, treat, or cure a sickness or injury.
Reasonable Fee means the benefit allowances as determined by the Trust for all
eligible expenses incurred by a participant. The basis will be the relative value
studies and schedules utilized and evaluated by the Trust. The benefit
allowances utilized by the Trust are determined by studies of charges for similar
benefits within a common geographical area. These studies are used to develop
benefit value schedules that are updated on a routine basis.
Ree:istered Graduate Nurse or Licensed Practical Nurse means a person duly
licensed by the state in which such person is engaged in the practice of nursing.
Rehabilitative Services means health care services for the purpose of which is to
restore functional defects.
Routine Care means services and supplies ordered and/ or provided by or under the
direction of a physician for the purpose of the diagnosis, treatment, or cure of a
sickness or injury.
Second Surgical Opinion means the second opinion contained in a written statement
on the necessity for the performance of a covered surgical operation given by a
board-certified specialist who, by the nature of the physician's specialty, qualifies
the physician to consider the surgical opinion being proposed and who is not
associated With the physician initially recommending the surgical operation.
· .Unless otherwise stated In the Schedule of Benefits (7/98)
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Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
Service Provider means a state licensed person or organization providing services
deemed to be covered expenses under this Plan.
Sickness means a bodily disorder, illness, or infirmity, which has been or is
diagnosed by a physician.
Skilled Nursinll Facility means a state licensed institution which provides '24 hour
nursing care for a patient whose condition does not warrant hospitalization and
has been approved for payment by the Trust. The facility can operate
independently or as part of a hospital.
Total Disability means a medically determinable physical or mental impairment
which renders a participant so incapacitated as to be unable to engage in any
gainful occupation, within the range of hisJher normal ability, and taking into
consideration education, training and work experience.
Trust means the Florida Municipal Insurance Trust, its Trustees and individuals or
organizations designated by the Trustees to act on their behalf.
SECTION II - DEDUCTIBLES
Individual Deductible - In the event the participant shall incur expenses for covered
medical services on or after their effective date of coverage, benefits will be
provided as follows for such expenses (except for any amount in excess of the
reasonable fee). Such expenses shall be subject to a deductible applicable under
this Plan, and as set forth in the Schedule of Benefits, for each covered
participant during each calendar year.
FamUy Deductible - All covered participants within a family shall be subject to the
maximum accumulative deductible as set forth in the Schedule of Benefits during
each calendar year.
-
Deductible credit from employer's prior coverage - In the event a participant has
incurred and paid covered expenses during a calendar year under any other
group health insurance plan issued to the employer which was in effect
immediately prior to the participant's coverage under this Plan, then the amount
of such covered and paid expenses shall be credited toward the participant's
deductible under this Plan for that calendar year.
SECTION III - LIFETIME MAXIMUM AND RESTORATION OF
BENEFITS
Each participant' is entitled to the services listed below when incurred while the Plan
is in force and when necessary and consistent with the accident or sickness for which
the participant is being treated.
Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
Subject to the provIsIons of this Section for each participant under this Plan, the
maximum liability of the Trust to such participant during the entire period such
participant is covered hereunder shall be the amount specified in the Schedule of
Benefits.
(l) If, at any time, benefits totaling at least $1,000 have become payable under
this Plan to any participant, the maximum liability of the Trust with respect to
such participant during the subsequent period such participant is covered
under this Plan may be restored to the amount specified in the Schedule of
Benefits upon receipt and approval by the Trust of evidence of such
participant's insurability. Such restoration will not be made during a calendar
year in which expenses were incurred. Evidence of insurability must be
furnished without expense to the Trust.
(2) If, during anyone calendar year, more than $1,000 in benefits has become
payable on behalf of a participant, said participant shall automatically be
entitled to $1,000 in restored benefits commencing with the next succeeding
year, regardless of whether the amount in the Schedule of Benefits has been
reached.
Items (1) and (2) of this Section do not pertain to the specific lifetime maximums of
limited benefits.
SECTION IV - MAXIMUM EXPENSE TO PARTICIPANTS
When the covered expenses of a participant reach the amount specified in the
Schedule of Benefits, subject to the coinsurance provisions, all further covered
expenses for that calendar year will be paid at 100% of the actual reasonable fees, up
to the Lifetime Maximum of the Plan.
SECTION V - ELIGIBILITY AND ENROLLMENT
Commencement of Coverage - Subject to any waiting period set forth under this
Plan and to any other condition of commencement expressed in this Plan,
coverage hereunder shall commence as follows:
(1) In the event an employer had no group health plan covering its employees and
dependents in effect immediately prior to the effective date of this Plan, all
employees in the employ of such employer on the effective date of this Plan,
and their eligible dependents, except a dependent that is totally disabled or a
dependent that has been exposed to the HIV infection or a specific sickness or
medical condition derived from such exposure, shall be eligible to participate
in this Plan. Coverage shall commence as of the effective date of the
Participation Agreement of the employer without proof of insurability provided
the Trust receives a properly and accurately completed and executed
enrol\ment form and any required medical statement application no later than
30 days following the effective date of the Participation Agreement. If
.. Unless otherwise stated In the Schedule of Benefits (7/98)
Page 7
Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
application is not received on or before the expiration of 30 days following the
effective date of the Participation Agreement of the employer, any application
for coverage by an employee, or his eligible dependents, will be governed by
the provisions set forth in Enrollment Paragraph (4).
(2) In the event an employee, or eligible dependents, were validly covered under a
group health insurance plan issued to the employer and in effect immediately
prior to the effective date of this Plan and such plan is discontinued and
replaced with this Plan, all such employees and eligible dependents actually
covered under such prior plan shall be eligible to participate in this Plan,
without interruption of coverage and without proof of insurability, unless such
employee or dependent is entitled to any extension of benefits in accordance
with S. 627.667, F,S., under the terms of the prior plan, and provided the
Trust receives a properly and accurately completed and executed enrollment
form, and any required medical statement application, no later than 30 days
following the effective date of the Participation Agreement of the employer. In
the event such employee or dependent is entitled to an extension of benefits in
accordance with S. 627.667, F.S., under the terms of the prior plan, such
employee or participant shall be entitled to participate in this Plan without
interruption of coverage and without proof of insurability provided the Trust
receives an accurately completed and executed enrollment form, and any
required medical statement application, no later than 30 days following the
effective date of the Participation Agreement of the employer; however, the
level of benefits under this Plan shall be no more than the applicable level of
benefits under this plan reduced by any benefits payable under the prior Plan.
Upon request, the employer, employee and dependent shall provide the Trust ,
such information as is reasonably necessary, including the prior plan, to
coordinate the level of benefits payable under this Plan and the prior plan, for
the Trust to verify the level of benefits provided under the prior plan, and to
determine each employee and dependent who was validly covered under the
prior plan on the date of discontinuance of the prior plan. If application is not
received on or before the expiration of 30 days following the effective date of
~e Participation Agreement of the employer, any application for coverage by
an employee, or his eligible dependents, will be governed by the provisions set
. forth in Enrollment Paragraph (4).
EHe:ibllity - Employees and eligible dependents shall be eligible for coverage on or
after the effective date of this Plan if:
(1) They fall within the classification set forth in the Employer's Participation
Agreement; and
(2) They have completed the period of continuous employment with the employer
as set forth in such classification.
An employee shall not be eligible as a dependent under the same employer group
except when both spouses are eligible employees and desire dependent child(ren)
coverage. In that case, one employee may cover the spouse and children as
dependents for health benefits and the spouse may be covered as a single
employee for other employee coverage(s).
Enrollment - Employees and eligible dependents may enroll for coverage under the
Plan by completing and submitting to the employer an accurately completed and
executed enrollment form provided by the Trust, as specified below:
Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
(1) lnitial eligibility period - within 30 days of satisfaction of the Plan waiting
period.
(a) New employees, and their eligible dependents, except totally disabled
dependents and dependents exposed to the HIV infection or a specific
sickness or medical condition derived from such exposure, shall be eligible
to participate in this Plan without proof of insurability, and shall commence
on the first billing date following the eligibility requirements set forth above.
If the enrollment form is not received on or before the expiration of the
period set forth above, any application for coverage by a new employee or
their dependents will be governed by the provisions set forth in Paragraph
(4) of this section.
(b) Except as otherwise provided in Commencement of Coverage Paragraph (2),
in the event an employee or eligible dependent is hospital confmed, totally
disabled or otherwise disabled when coverage would otherwise begin,
coverage will begin the billing date of the month following the employee or
dependent's return to good health when able to perform the normal
activities of a well person of the same age and sex. This subsection does
not apply to a newborn child of an employee covered for dependent coverage
at the time of birth.
(c) In the event an employee's coverage terminates due to termination of
employment and such employee returns to full-time employment within
ninety (90) days, such employee's coverage may be reinstated without
completing the period of continuous employment set forth in the Employer's
Participation Agreement, provided an enrollment form is received by the
Trust within thirty (30) days of the employee's return to employment. If the
enrollment form is received more than thirty (30) days after the employee's
return to employment, any application for coverage will be governed by the
provisions set forth in Paragraph (4) of this section.
(d) In the event an employee was covered under this Plan through another
employer within thirty (30) days prior to beginning employment with this
employer, such employee will not be required to complete the period of
continuous employment set forth in the Employer's Participation
Agreement, provided an enrollment form is received by the Trust within
thirty (30) days of beginning employment with this employer. Required
contributions must be paid at the new employer's rates from the prior
billing date for reinstatement of continuous coverage. If the enrollment
form is received more than thirty (30) days after the employee's return to
employment, any application for coverage will be governed by the provisions
set forth in Paragraph (4) of this section.
(e) Pre-existing limitations will apply, as outlined in Section X.
(2) Open enrollment period - within 30 days of the Plan's policy renewal
anniversary. Eligible employees can enroll in the Plan or terminate coverage
during the open enrollment period. Pre-existing limitations will apply, as
outlined in Section X, If application is received 30 days or more following the
Plan's policy renewal anniversary, any application for coverage by an employee
or eligible dependents will be governed by the provisions set forth in Paragraph
(4) of this section.
..,'............_......~~,l~. ..._..~....~<..L. -, I' ,t." .....,. ._ .__
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
(3) Soecial enrollment period - within 30 days of certain events or loss of coverage
as ou tlined below:
(a) An eligible employee andj or eligible dependent except a totally disabled
dependent or a dependent exposed to the HIV infection or a specific
sickness or medical condition derived from such exposure, was:
<D covered under another health benefit plan as an employee or dependent,
or COBRA continuation of coverage at the time of initial eligibility to
enroll for coverage under this Plan, and
a> When offered coverage under this Plan at the time of initial eligibility
stated, in writing, that coverage under another health plan was the
reason for declining enrollment, and
a> Demonstrated that loss of coverage under an individual or group health
benefit plan occurred within the past thirty (30) days as a result of legal
separation, divorce, death, termination of employment, or reduction in
the number of hours of employment, and
@ Requests enrollment within thirty (30) days after the termination of
coverage under another health benefit plan.
(b) An individual who loses coverage as a result of termination for failure to pay
premiumsjprepayment fee on a timely basis, or the discontinuance of any
contributions toward the health coverage plan by the employer, or for cause
does not have the right to special enrollment under this Plan. Voluntary
termination of coverage does not constitute loss of eligibility of coverage.
(c) A newly eligible dependent, except a totally disabled dependent or a
dependent exposed to the HIV infection or a specific sickness or medical
condition derived from such exposure, as a result of marriage, birth,
adoption or placement for adoption, legal guardianship or court order,
without proof of insurability provided the Trust has received an accurately
completed and executed enrollment form, within thirty (30) days of the
event. Eligible dependents may only be enrolled if the eligible dependent is
a dependent of an employee who is already participating in the Plan. If the
employee fails to apply within the thirty (30) day period, any application for
coverage will be governed by Paragraph (4) of this Section.
<D In the event of marriage, the effective date of coverage shall be the frrst
day of the month following receipt of notification by the Trust.
a> In the event of a newborn, coverage will take effect on the date of birth
and will continue for thirty (30) days. Coverage beyond this period
requires the enrollment form as specified above. If application is not
received during this time period, the Trust reserves the right to charge
an additional premium for coverage of such newborn from date of birth
to the date of receipt of application or the end of the thirty (30) day
period.
a> In the event of an adoption of a newborn child, if a written application to
adopt. a newborn child has been entered into by the employee prior to
the 1?irth of the child, such child shall be subject to the conditions and
entitled to the benefits and services provided in this Plan applicable to
newborn children provided the child is ultimately adopted pursuant to
Ch. 63, F.S. As a condition of coverage, the written agreement shall
Flonda Municipal Insurance Trust
Medical Master Plan of Beneflts
accompany the employee's supplemental application for 'coverage for
such child. As a condition of continued coverage, the employee shall
immediately provide the Trust with a certified copy of the judgment of
adoption upon its entry and the employee shall, upon request, provide to
the Trust, under oath, such information as is reasonably necessary to
keep the Trust apprised of the stage of the adoption proceeding.
@ In the event of an adoption or placement for adoption (other than
newborn), legal guardianship or court order, the effective date of
coverage shall be from the date of the child's placement in the
employee's residence or date specified by court order. If application is
not received within thirty (30) days of the effective date, the Trust
reserves the right to charge an additional premium for coverage of such
child(ren) from the effective date to the date of receipt of application. As
a condition of coverage, the employee shall provide the Trust with a
certified copy of the judgment of adoption, guardianship or court order.
(d) Pre-existing limitations will apply, as outlined in Section X.
(4) Those eligible employees who refuse coverage for themselves or their eligible
dependents under this Plan, those employees applying for coverage, including
dependent coverage, under this Plan subsequent to the effective date of the
Participation Agreement of the employer, or those employees and dependents
who do not satisfy the coverage provisions specified in Paragraphs (1), (2), and
(3) of this Section may apply for coverage at a later date by medical statement
application. Such employee, on behalf of himself/herself or his/her
dependents, shall provide the Trust with a completed medical statement
application and such applicants shall be subject to the applicable rules and
regulations of the Trust. The Trust will review all medical statement
applications and provide the eligible employee's employer with a notice of
acceptance or notice of rejection. If accepted, the effective date of coverage for
such applicant shall be the frrst day of the month following the receipt of
notice of such acceptance. Pre-existing limitations will apply, as outlined in
Section X.
The employer shall submit such form and any required medical statement
application, together-with any contribution due to the Trust, as a prerequisite to
the coverage of such employee or dependent under this Plan.
Certificates of creditable coverage, as specified in Section X, should be provided at
the time an application for enrollment is made by the eligible employee and their
eligible dependents.
The employer does not act as an agent of the Trust in the enrollment and
withdrawal of its employees and their eligible dependents. Notwithstanding, and
in addition to, any other conditions expressed herein for coverage or payment of
benefits and services, coverage for each employee and eligible dependents under
this Plan shall commence no earlier than the first day of the month immediately
following the date on which the Trust has actually received a properly and
accurately completed and executed enrollment form and any required medical
statement application and the contribution attributable to the particular
employee and eligible dependents.
a 6.1_1___ _....---..1.__ ___... 1_ ...._ r_....-A..I.. A' RAftAflh 17 IQA\
Page 11
Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
SECTION VI - COVERED EXPENSES
If the employer and the participant have satisfied the terms and conditions provided
in this Plan for coverage and for the payment of benefits and services, the participant
is entitled to the benefits and services listed below when incurred while the Plan is in
force and when medically necessary and consistent with the accident or sickness for
which the participant is being treated. The Trust will pay the reasonable fee for such
benefits and services and, all such benefits and services, unless otherwise expressly
provided herein, shall be subject to any calendar year deductible andj or coinsurance
shown on the Schedule of Benefits.
Pre-Admission Certification - All non-emergency hospital admissions must be:
(1) certified seven (7) days prior to a planned admission;
(2) certified within 48 hours or the first working day after the admission.
Failure to obtain certification will result in a 20% reduction of benefits paid.
Pre-admission certification is not required for the birth of a child, provided the
hospital or birthing center length of stay does not exceed:
( 1) 48 hours following a vaginal delivery, or
(2) 96 hours following a cesarean delivery.
Inpatient Hospital Services - The expense incurred for the following services will be
paid as stated in the Schedule of Benefits (in excess of any deductible andj or
coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the
end of the calendar year whichever frrst occurs.
(1) Hospital room and board up to but not to exceed the average semi-private
room rate. **
(2) Intensive care unit (including cardiac and neonatal care units) not to exceed
three (3)** times the average semi-private room rate.
(3) Progressive care unit up to but not to exceed one and one-half (1 V2 ) time.s the
average semi-private room rate only if incurred immediately following a
confmement in an intensive care unit,
(4) Miscellaneous services and supplies provided such as operating and recovery
room charges, x-ray and other diagnostic procedures, laboratory tests,
pathological services, medications and dressings,
(5) Transfusion supplies and services including blood administration expenses
but not including blood, blood plasma and/or blood derivatives unless
otherwise specifically stated in this Plan.
(6) Anesthesia services, including supplies, equipment and physician's charges
for regional, intravenous, inhalation, intraspinal and caudal anesthesia
services when performed by a regular salaried hospital employee and when
performed in connection with surgical, obstetrical**, electro-shock, or dental
services~* covered under this Plan.
(7) Oxygen therapy, diathermy and physiotherapy.
(8) Roentgenologic (x-ray) and cobalt bomb therapy when such therapy is m
Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
connection with proven malignancies or for radium, radon or isotope therapy,
(9) Obstetrical Care.. - Maternity benefits will be provided to participants,
subject to the same limitations and exclusions applied to as all other benefits
provided under this Plan; provided, however, dependent children shall not be
entitled to maternity benefits. Complications of pregnancy (excluding false
labor, occasional spotting, prescribed rest, morning sickness, hyperemesis
gravidarum, pre-eclampsia and similar conditions not constituting a
nosologically distinct complication) are eligible for benefits on the same basis
as any other illness.
(10) Newborn Care - Eligible hospital services as provided herein for participants
shall also be provided for a newborn dependent child of a participant from
the moment of birth and shall include mentally diagnosed congenital defects,
birth abnormalities or prematurity. A newborn infant of a dependent child is
eligible and shall be covered so long as the dependent child is covered under
the provisions of this Plan but not to exceed eighteen (18) months.
Physician Services - The expenses incurred for the following physician services will
be paid as stated in the Schedule of Benefits (in excess of any deductible and/ or
coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the
end of the calendar year whichever first occurs.
(1) Surgical Services - wherever performed, limited to operative procedures for
the treatment of accident or sickness. The surgical allowance includes post-
operative treatment.
(2) Surgical Assistant - provided the assistance is medically necessary, no intern,
resident, or other staff Physician is available, and the condition of the patient
and the type of eligible surgery performed require such assistance.
(3) Consultations - which are medically necessary due to complications,
complexity or different diagnosis. A consultation report must be part of the
hospital medical records.
(4) Anesthesia Administration - when rendered in connection with a covered
surgical or obstetrical" procedure.
is) Obstetrical Care" - this expense will be considered incurred at the
termination of the pregnancy. Dependent children shall not be entitled to
maternity benefits.
(6) Professional Component Expenses - of radiology, pathology and laboratory.
(7) Medically Necessary Hospital Visits - not including post-operative treatment.
(8) Medically Necessary Care - rendered outside of the hospital. Routine
physical examination expenses are not covered, unless otherwise specifically
stated in the Schedule of Benefits.
(9) Dental Care and Treatment - rendered by a physician or dentist within ninety
(90) days of an accident when, as the result of the accident, natural teeth
have been damaged or fractured or a dislocated jaw requires setting.
(10) Concurrent Care - combining medical surgical and obstetrical" care whereby
the Trust will pay for necessary eligible medical, surgical, or obstetrical** care
and nec'essary eligible surgical obstetrical" care in addition to other eligible
medical expense during a single hospital confinement.
. .Unl~ otherwise mte<! 'n the Schedule of Beneflb (7/98)
Page 13
Ronda Municipal Insurance Trust
Medical Master Plan of Ben.flb
(ll) Well Child Care - the reasonable fees charged by a physician for physicals,
examinations, developmental assessments, anticipatory guidance,
immunizations and laboratory tests, in keeping with prevailing medical
standards, which are not required for the treatment of illness or injury, for
covered dependent children from the moment of birth to sixteen (16) years of
age, are payable subject to the following:
(a) A lifetime maximum of eighteen visits at the following age intervals; birth,
two months, four months, six months, nine months, twelve months,
fifteen months, eighteen months, two years, three years, four years, five
years, six years, eight years, ten years, twelve years, fourteen years and
sixteen years.
(b) Benefits are limited to one visit payable to one physician for all service
provided at that visit.
(c) The benefit is not subject to the calendar year deductible, but is subject
to the coinsurance, if applicable.
(12) Therapeutic Treatment - by a radiologist including radium, radon, isotope, x-
ray and cobalt bomb therapy when in connection with proven malignancies.
(13) Newborn Care - when rendered by a physician to a newborn dependent child
of a participant, from the moment of birth, for covered injury or sickness,
including necessary care or treatment of medically diagnosed congenital
defects, birth abnormalities, or prematurity. A newborn infant of a
dependent child is eligible and shall be covered so long as the dependent
child is covered but not to exceed eighteen (18) months.
Other Medical Services - The expenses incurred for the following services will be
paid as stated in the Schedule of Benefits (in excess of any deductible andj or
coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the
end of the calendar year whichever first occurs.
(1) Emergency Professional Ambulance Service - to the nearest hospital able to
provide the care required for the patient. Transportation costs of a newborn
to and from the nearest available facility appropriately staffed and equipped
. to treat the newborn's condition, when such transportation is certified by the
attending physician as necessary to protect the health and safety of- the
newborn child shall be covered. The coverage of such transportation costs
shall not exceed the reasonable fees, and in no event shaJ.1 exceed the sum of
$1,000,**
(2) Prosthetic and Other Devices - initial (under this Plan) appliances, crutches,
braces, cardiac pacemakers, standard model wheelchair, or other mechanical
appliances medically necessary for the correction of conditions arising out of
injuries or sickness, provided the equipment is prescribed by a physician,
and the equipment does not, in whole or in part, serve as a comfort or
convenience item. Written approval must be obtained by the Trust for
prosthetics and other devices which exceeds $500 in cost. The Trust shall
have the right to buy or rent such appliances as they may elect.
(3) Splints, Casts, Trusses.
.
(4) Other Durp.ble Medical Equipment Rental- required for temporary therapeutic,
provided the equipment is prescribed by a physician, and the equipment does
not, in whole or in part, serve as a comfort or convenience item. Written
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Ronda Munlclpallnsur8nce Trust
Medical Master Plan of Benefits
approval must be obtained by the Trust for prosthetics and other devices
which exceeds $500 in cost.
(5) Initial Eye Glasses or Contact Lens - resulting only from cataract or glaucoma
surgery (including those surgically implanted).
(6) Hospital Charges - for emergency room care or for surgical service.s performed
in the outpatient department of a hospital.
(7) Alternative Housing - in close proximity to a medical facility located in the
state:
(a) If the Trust finds a bone marrow transplant otherwise covered under the
terms of this Plan has been performed on the participant at the medical
facility;
(b) Due to the special nature of the bone marrow transplant procedure, it
can be performed in no more than four medical facilities in the state the
participant does not reside within 45 minutes driving time to the medical
facility;
(c) Due to the special nature of the bone marrow transplant procedure, it is
medical necessary for the participant to remain over a prolonged period of
time in close proximity to the medical facility in which the procedure was
performed in order to closely monitor potential post-procedure
complications directly related to the procedure;
(d) The costs of the physician-directed inpatient hospital stay would far
outweigh the cost of outpatient services combined with the alternative
housing.
(e) The above findings and decisions to permit alternative housing, including
those related to medical necessity, and the type, location, cost, length of
stay and nature of the alternative housing, shall be within the sole
discretion of the Trust. The fact that a physician may prescribe, order,
recommend, or approve the alternative housing does not of itself make it
medically necessary or make the expense an allowable expense,
(f) Notwithstanding the other terms, conditions and limitations provided in
this subsection, the Lifetime Maximum under this section is $10,000**.
Supplemental Accident Benefit - Services under this Plan will be provided, as stated
in the Schedule of Benefits, for each accident when expenses are incurred, as the
result of an accident for medical, surgical, and hospital care and treatment,
within ninety (90) days subsequent to an accident not connected with
employment and when such treatment has been prescribed by a physician.
Expenses which are incurred after the ninety (90) day period or after the
maximum for each accident has been reached, will be paid as regular Plan
benefits, subject to the deductible and/ or coinsurance provisions of this Plan.
Diagnostic X-ray. Laboratorv and Patholopcal Services - Services for outpatient
hospital ~d physician charges for diagnostic x-ray, laboratory and pathology
required for the treatment of an illness shall be paid in accordance with the
schedule. of benefits.
Chiropractic Services - The reasonable fees for chiropractic services shall be
covered, subject to all Plan provisions, deductibles and coinsurance.
Ronda Municipal Insurance Trust
Medical Master Plan of Beneftts
Pre-Admission Laboratory or Radiolo~ Testinl - The expenses incurred for pre-
admission laboratory or radiology testing will be payable at 100% of the
reasonable fees, not subject to the calendar year deductible. The testing must be
ordered by a physician, must not be duplicated by the hospital and must be
performed no later than four (4) days prior to an inpatient hospital confmement or
an outpatient surgical procedure in order to be covered by this provision. All
other expenses incurred for pre-admission laboratory or radiology testing shall be
subject to the calendar year deductible and coinsurance.
Physical Therapy Services - Services of a Physical Therapist for physical therapy
provided such services are provided on an outpatient basis and further provided
such services are limited to 40 visits, up to a $2,000** per calendar year
maximum.
Second SurJical Opinions - Second surgical opmlOns may be required prior to
surgery for the following surgical procedures:
(l) Arthoplasty - plastic operation on a joint or the formation of an artificial joint
when performed on the knee or hip;
(2) Arthroscopy - internal examination performed by the use of a scope, when
performed on the knee;
(3) Cholecystectomy - removal of the gall bladder;
(4) Coronary Bypass and Pacemaker Insertion;
(5) Dilation and Curettage (D&C);
(6) Hemorrhoidectomy - removal of a mass of swollen varicose veins in the rectal
mucous membrane;
(7) Hysterectomy - removal of the uterus by excision;
(8) Laminectomy or Laminotomy - removal of or incision into a disk;
(9) Prostatectomy - excision of the prostrate gland;
( 10) Subcutaneous Mastectomy - excision of cyst, tumor, or lesion of the breast;
(11) Submucous resection/ rhinoplasty - surgical correction of deviated septum,
. plastic surgery on the nose;
(12) Tonsillectomy/adenoidectomy - removal of the tonsils and adenoids.
Mental and Nervous Disorders** - The reasonable fees of the services of physicians,
psychiatrists, licensed psychologists who hold a PsyD, and hospital for the
treatment of mental and nervous disorders, as defmed in the standard
nomenclature of the American Psychiatric Association, limited to the maximum
number of visits shown on the Schedule of Benefits, up to a $10,000 per calendar
year maximum and a $25,000 lifetime maximum.
Medicare SuplJlement Benefits - A participant over the age of 65 who retires from
the employ of the employer while this Plan is in force is eligible for the Medicare
Supplement coverage of this Plan. The supplement benefits are:
(l) For initial hospital expenses for confmement as a hospital inpatient, the Plan
will pay ~e Part A Medicare deductible.
(2) For hospital inpatient expenses from the 61st day through 150th day of
confinement per spell of illness, the Plan will pay the amount of the daily
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Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
Medicare deductible.
(3) The Medicare Part B deductible is paid by the Plan at 100% per calendar
year.
(4) The Medicare Part B coinsurance is paid by the Plan for eligible reasonable
fees incurred as determined by Medicare,
(5) Prescription Medicines - When ordered by a physician, consistent with the
treatment of a specific diagnosis, when dispensed by a licensed pharmacist,
and when obtained through the mandatory prescription program provided in
Section XVI of this Plan. Vitamins, minerals, and over-the-counter
medications are not eligible expenses. Expenses are subject to the individual
calendar year deductible and coinsurance as set forth in the former
employer's Schedule of Benefits.
(6) The Lifetime Maximum for all Medicare Supplement benefits is $1,000,000.
Alcohol and Drue: Dependency Benefit - As used in this Section "alcoholic" means a
participant who chronically and habitually uses alcoholic beverages to the extent
that it injures his/her health, substantially interferes with his/her social or
economic functioning, or to the extent that he/she has lost the power of self-
control with respect to the use of such beverages. As used in this Section "drug
dependent" means a participant who is dependent upon, or by reason of repeated
use is in eminent danger of becoming dependent upon, any substance controlled
under Ch. 893, F.S.
The reasonable fees incurred as a result of the necessary care and treatment of an
alcoholic or a drug dependent shall be covered, subject to the following terms,
conditions and limitations:
(1) Care and treatment must be provided by, provided under the supervision of,
or prescribed by a state licensed physician or psychologist;
(2) Care and treatment must be pursuant to a program accredited by the Joint
Commission on Accreditation of Hospitals or approved by the State of Florida;
(3). Benefits are limited to coverage stated on the Schedule of Benefits, with a
$4,000 lifetime maximum;
(4) Detoxification will not be considered a benefit under an outpatient program.
Midwifery and Birth Center Benefit - The reasonable fees for midwifery services
performed by a Certified Nurse Midwife or midwife and the reasonable fees
incurred by a Birth Center for services and supplies furnished to a participant for
prenatal care, delivery and postpartum care rendered within twenty-four (24)
hours of delivery shall be covered, subject to all Plan provisions, deductibles, and
coinsurance; provided, however, dependent children shall not be entitled to this
benefit.
Hospice Care Benefit - A participant will be eligible for hospice care benefits under
this Plan if written approval is provided in advance by the Trust. The Trust will
not provide written approval unless a written statement is submitted to the Trust
by the Hospic; Care Agency and the attending physician outlining:
(l) and attesting that the patient is terminally ill,
(2) and attesting that the patient has a life expectancy of six (6) months or less,
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
(3) the range of charges for services that will or could be rendered.
Hospice care benefits are for reasonable fees incurred for the palliation or
management of terminal illness. Benefits shall be payable for the routine home
care, and continuous home care subject to a Lifetime Maximum of $6,000**, for a
maximum period of six (6) months. Hospice care will only be approved o~ce for a
participant.
TMJ Benefit - The reasonable fees charged by a hospital, dentists, or physicians for
the treatment of temporomandibular joint dysfunction are eligible for benefits up
to a Lifetime Maximum of $1,500** for all services related to this condition. Only
one $1,500.** lifetime benefit will be provided.
Cardiac Rehabilitation Benefit - Service of a state licensed cardiac rehabilitation
facility for cardiac rehabilitation on an outpatient basis up to a Lifetime Maximum
of $2,000** provided such services are prescribed by a physician and provided
under the direct supervision of a physician. A participant who is eligible for this
benefit must meet the following criteria:
(1) Myocardial Infarction - post myocardial infarction patient may enter the
program anytime, at the discretion and referral from physician;
(2) Post-op Cardiovascular Surgery - a minimum of three weeks aorta - coronary
bypass surgery, or discretion and referral from physician;
(3) Adequate control of complications, i.e., angina, congestive heart failure or
arrhythmias;
(4) Pacemaker patients with any of the above diagnosis andjor decreasing
functional capacity.
Home Health Care Benefit - The reasonable fees, up to a maximum calendar year
benefit of $1,000, incurred for home health services performed by a home health
agency resulting from an accident or sickness to a participant while this Plan is in
force shall be covered, subject to all Plan provisions, provided the services are
performed pursuant to a written plan of treatment prescribed by a physician that
is approved in advance by the Trust.
Skilled Nursing Facility Benefit - Services and supplies provided under the direction.
of a physician, provided the services are performed pursuant to a written plan of
treatment prescribed by a physician that is approved in advance by the Trust.
Mastectomy Benefit - The reasonable fees for inpatient hospital and physician
services associated with the surgical removal of all or a part of the breast if
determined medically necessary by a licensed physician, prosthetic devices, and
reconstructive surgery incident to the mastectomy, shall be covered, and subject
to the following conditions and limitations:
(1) Coverage for prosthetic devices and reconstructive surgery shall be limited to
the initial prosthetic device and initial reconstructive surgery incident to the
mastectomy;
(2) If the mastectomy reveals no evidence of malignancy, coverage for prosthetic
devices and reconstructive surgery incident to the mastectomy is limited to
an initial prosthetic device provided, and to medically necessary
reconstructive surgery performed, within two (2) years of the date of the
Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
mastectomy.
Mammo~m Benefit - The reasonable fees for mammogram testing, breast cancer
screening or diagnostic services, and health testing services utilizing radiology
equipment (registered with the state's Department of Health and Rehabilitative
Services) for breast cancer screening shall be covered, and according to ~ese
guidelines: '
(1) One baseline mammogram for women ages 35 to 40;
(2) One mammogram every 2 years, or more frequently if prescribed by the
participant's physician, for women ages 40 to 50;
(3) One mammogram, every year for women 50 years of age and over.
Heart. Heart-Luna:. Bone Marrow. Cornea Tissue. Kidnev and Liver Transplant
Benefits - The reasonable fees for inpatient hospital and physicians services
associated with a heart, bone marrow, cornea tissue, kidney or liver transplant
provided the participant meets objective criteria set forth by the medical industry
for the tissue or organ transplant, the transplant procedure is performed in a
facility duly licensed to facilitate the procedure by a physician duly credentialed to
perform the transplant, the procedure is approved by the U.S. Food and Drug
Administration, the transplant tissue or organ is donated to the participant and
not purchased through an outside agent, and the transplanted tissue or organ
originated from a human being and not from cadavers, animal laboratories, or
other experimental sources.
Due to the extensive nature of the services related to transplantations, a pre-
determination must be obtained from the Trust.
SECTION VII - HOSPITAL BILL SELF-AUDIT
The Trust will provide a payment to the participating employee in the amount of 50%
of the savings (the total dollar difference between the original bill and the revised bill),
not to exceed $1,000,
The employee will receive a payment from the Trust for any errors that the employee
identifies and the hospital corrects.
The following steps must be taken by the participant before contacting the Trust:
(1) Obtain a copy of the itemized bill before leaving the hospital or make
arrangements for an itemized bill to be sent to you.
(2) Review the hospital bill for overcharges or errors on the bill.
(3) If the participant feels an error was made, the business office of the hospital
must be contacted to review the possible error(s).
(4) Request the business office of the hospital to satisfactorily explain the
possible errorJs) or issue a revised bill, which contain the credit(s) for the
incorrect charge(s). .
(5) Send the revised bill to the Trust with a letter outlining your actions, the
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
for reverse sterilization.
(l3) Infertility or medications prescribed to assist with fertility.
(14) Contraceptive devices or appliances.
(l5) Services, supplies or medications prescribed for the treatment of sexual
disorders.
(16) Artificial insemination or in vitro-fertilization andj or any other form of
artificial impregnation.
(17) Elective abortions.
(l8) Services associated with autopsy or postmortem examination, including the
autopsy.
(19) Blood and blood plasma.
(20) Services or supplies associated with the treatment of morbid obesity,
including gastric bypasses, gastric balloons, stomach stapling, jejunal
bypasses, jaw wiring, and services of a similar nature unless medically
necessary. Services and supplies associated with weight loss programs,
nutritional supplements, appetite suppressants, and supplies of a similar
nature.
(21) Private duty nursing by an RN or LPN whether in an inpatient hospital
setting or skilled nursing facility.
(22) Biofeedback and other forms of self-care or self-help training and any related
diagnostic testing, including exercise programs.
(23) Foot care not related to the diagnosis or treatment of a condition.
(24) Nicotine withdrawal programs, facilities and supplies.
(25) Transplants of any type except heart, heart-lung, bone marrow, cornea
tissue, kidney, and liver transplants.
(26) Services or supplies which, in the opinion of the Trust, are experimental or
not provided in accordance with accepted professional medical standards in
the United States.
(27) Services and supplies which, in the opinion of the Trust, are not medically
necessary for the diagnosis or treatment of illness, injury or bodily
malfunction. The fact that a physician may prescribe, order, recommend, or
approve a service or supply does not of itself make it medically necessary or
make the expense an allowable expense.
(28) Professional medical or surgical services rendered by an individual who is
related to the covered participant by blood or marriage.
(29) Treatment, care, services or supplies which are obtained without cost to the
participant.
(30) Service or supplies furnished to a participant or paid under any of the
following plans or insurance coverages:
(a) Any plan, 'program or insurance policy providing benefits for hospital,
medical andj or other health care expenses under a group master policy
including: but not limited to, policies issued to any health maintenance
organization or any entity to which such policies may legally be issued in
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Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
amount of savings and your request for payment.
SECTION VIII - EXCLUSIONS AND LIMITATIONS
Unless otherwise expressly covered in Section VI of the Plan, coverage under this
Plan for participants is subject to the following exclusions ,and limitations for
which no benefits shall be paid:
(1) Services or supplies for beautifying or cosmetic purposes unless:
(a) necessitated by an accidental injury while covered under this Plan and
performed within six (6) months following the date of the accident, and
(b) required to restore a normal bodily function,
(2) Services or supplies provided by any custodial institution, rest home, nursing
home, sanitarium, health spa, health resort, place of rest, institution or home
for the aged, drug addicts, or alcoholics, or a place for the treatment of
pulmonary tuberculosis or mental or nervous disorders.
(3) Fees for routine physical examinations or periodic check-ups, except as
otherwise specifically stated in this Plan.
(4) Any service or supplies to a participant hospitalized for primarily rest,
restj cure or primarily for observation.
(5) Services or supplies for injury or sickness resulting from drug or alcohol
abuse, or resulting from intoxication or consumption of drugs or alcohol.
(6) Eye refractions, keratotomies, eye glasses, hearing aids and examinations or
the prescription or fitting thereof, eye exercise, visual training or orthoptics.
(7) Travel expenses, whether or not travel is recommended by a physician.
(8) Hospital service or supplies for a participant who shall remain in a hospital
after the attending physician advises that further hospital service is
unnecessary .
. (9) Dentist, physician or hospital expenses for dental care and treatment
including treatment or removal of teeth and immediately adjacent structures
(ie. gingival) and any services for orthodontia, prosthodontia, periodontia and
preparation for dentures unless, as a result of an accident, natural teeth
have been damaged or a fracture or dislocated jaw requires setting, and then
only if such dental treatment is rendered within ninety (90) days from the
date of the accident.
(10) Massage unless the massage is prescribed by a physician, which prescription
specifies the number of treatments and is performed under the direct
supervision of a physician or by a massage therapist, and is approved in
advance by the Trust.
(11) Services or supplies for the primary purpose of providing rehabilitation to a
participant including, but not limited to, rehabilitative services related to
alcohol and drug abuse or accident or sickness arising therefrom,
occupational therapy, speech therapy, and pain management training and
educational programs.
(12) Services or supplies for surgery for sexual reassignment or reconstruction, or
Ronda Municipal Insurance Trust
Medical Malter Plan of Beneflts
the State of Florida for the purpose of insuring a group of individuals;
(b) Any plan, program or insurance policy, andjor PIP automobile insurance
as required and defined in the Florida Statutes, which provides benefits or
makes payments to or on behalf of a participant for hospital, medical
andj or other health care expenses;
(c) any group contract issued to this Trust;
(d) Any coverage under a plan or a law of any federal, state or local
government or any political subdivision thereof, including but not limited
to, coverage under Medicare, andjor any other federal, state or local
government-sponsored program or programs, unless otherwise provided
by law;
A participant shall have no right to benefits under this Plan if said
participant elects to waive any entitlement to benefits provided under any
plan described in this paragraph. The participant shall provide, execute and
deliver such information, instruments and papers, and do whatever else is
necessary to secure the instruments and papers, and the Trust's rights under
this paragraph.
(31) Expenses that are covered under Parts A and B of Medicare, if the participant
is not an active employee or the dependent of an active employee.
(32) Treatment andj or drugs received in a veterans hospital or government facility
due to a service connected disability.
(33) Any service or supplies provided before coverage begins or after coverage
terminates, for the group or for the participant, except to the extent and in
the manner provided by Florida law and in the manner provided under
Sections X, XIII, XIV and xv.
(34) Personal comfort articles such as beauty and barber services, radio, and
television.
(35) All other services or supplies not furnished by a hospital for inpatient andj or
. outpatient treatment or specifical.ly listed as covered expenses.
(36) Discounts applied to total expenses by health care providers will not be used
to satisfy deductibles or coinsurance under this Plan.
(37) Any treatment for injury or sickness which a contributing cause was the
participant's commission of, or attempt to commit, a felony, or the participant
being engaged in any illegal act.
(38) Preexisting conditions, except to the extent and in the manner provided in
Section X.
(39) Services or supplies for any occupational condition, ailment or injury arising
out of or in the course of employment for wage or profit or any other endeavor
for potential profit or gain, or services which are furnished to a participant
under the laws of the United States or any state or political subdivision
thereof, for which the participant shal.l have no right under this Plan, even
though the participant elects to waive that right to such benefits or service.
(40) Services or supplies for injury or illness resulting from suicide or attempted
suicide, self-inflicted injury or self-induced illness, whether sane or insane.
This includes participation in and/ or incitement of an altercation.
Ronda Municipal Insurance Trust
Medical Master Plan of Benefits
(41) Services or supplies for injuries sustained or sickness contracted while in
any military force of any country while such country is engaged in war or
hostilities (whether or not declared), or while performing police duty as a
member of any military organization.
(42) Services or supplies for injury or illness that results from deliberately and
voluntarily undertaking activities that subject the participant to unnecessary
exposure to danger or unnecessary exposure to obvious risk of injury. This
exclusion shall not apply to services or supplies for injury or illness resulting
from the participant's participation in sponsored sporting events or
traditional recreational activities.
(43) Services or supplies for complications, which result from or arise out of the
provision of services or supplies that are excluded under this Section.
(44) Fees in excess of the percentage specified in the Schedule of Benefits, or in
excess of reasonable fees.
Benefits payable under this Plan will be limited to services provided and expenses
incurred within the continental United States. Any expenses incurred by a
participant outside the continental United States will be subject to approval by the
Trust.
SECTION IX - COORDINATION OF BENEFITS
The purpose of health care coverage is to help meet actual expenses. In line with that
purpose, this Plan contains a non-profit provision coordinating it with other plans,
including group plans under which a participant is covered, so that the total benefits
available will not exceed 100% of the allowable expenses.
Primary Coverage - A plan without a coordinating provision is always the primary
plan. . If all plans have this provision:
(1) !he plan covering the person as an employee rather than as a dependent is
primary;
(2) the plan covering the person as an active employee or as a dependent of an
active employee rather than Medicare is primary;
(3) if a child is covered under both parents' plans, the plan for the parent with
the earliest birthdate in the calendar year is primary;
(4) if a dependent child is covered under both parents' plans, and both parents
have the same birthday, the plan which has covered the parent for a longer
period of time is primary;
(5) if a dependent child is covered under both parents' plans, and the parents
are divorced or separated, the primary plan will be determined in the
following ord~r:
· First, the plan of the parent with custody of the child;
· Secbnd, the plan of the spouse of the parent with the custody of the child;
and
· Third, the plan of the parent not having custody of the child;
Ronda Munlclpallnsurlnce Trust
Medical Master Plan of Benefits
unless the specific terms of a court decree state that one of the parents is
responsible for the health care expenses of the child in which case the plan
covering such parent is primary. A copy of the court decree must be
furnished to the Trust;
(6) The Plan covering an employee, or the employee's dependents, rather than a
retiree, or the retiree's dependents, is primary;
(7) The Plan covering a person as an employee who has not retired, or the
employee's dependents, rather than the plan covering a person, or the
person's dependents, as a retiree, is primary;
(8) The Plan covering a person as an employee, or the employee's dependents,
rather than a plan covering the person, or the person's dependents, under
COBRA, shall be primary.
If none of the above rules apply, the plan that covered an employee or dependent
for a longer period of time is primary.
Secondary Coverage - Services and benefits under this Plan will be coordinated with,
and this Plan is hereby deemed secondary to plans providing coverage for
services, supplies or benefits furnished to a participant or paid under any of the
following plans of insurance coverage:
(1) any plan, program or insurance policy providing benefits for hospital, medical
andj or other health care expenses under a group master policy including, but
not limited to, policies issued to any health maintenance organization or any
entity to which such policies may legally be issued in the State of Florida for
the purpose of insuring a group of individuals;
(2) any plan, program or insurance policy andjor PIP automobile insurance as
required and defmed in the Florida Statutes, which provides benefits or makes
payments to or on behalf of a participant for hospital, medical andj or other
health care expenses;
(3) any group contract issued to this Trust;
(4) any coverage under a plan or law of any federal, state or local government or
any political subdivision thereof, including but not limited to, coverage -under
Medicare andj or any other federal state or local government-sponsored
program or programs, unless otherwise provided by law.
(5) A participant shall have no right to benefits under this Plan if said participant
elects to waive any entitlement to benefits provided under any plan described
in this paragraph. The participant shall provide, execute and deliver such
information, instruments and papers, and do whatever else is necessary to
secure the instruments and papers, and the Trust's rights under this
paragraph,
SECTION X - PRE-EXISTING CONDITIONS LIMITATIONS
There is no coverage under this Plan for services or supplies to treat a pre-existing
condition or conditions arising from a pre-existing condition, until the participant has
been continuously covered under this Plan:
(1) for a 12 month period beginning on the date of hire for employees and their
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
dependents who enroll in the Plan during the initial enrollment period, and
(2) for a l2 month period beginning on the effective date for employees and their
dependents who enroll in the Plan during the open enrollment period and the
special enrollment period.
All participants enrolled subsequent to the effective date of this Plan will be subject to
this pre-existing condition limitation, except newborn or adopted dependents th'at are
properly enrolled in accordance with this Plan.
Credit will be given for the time an eligible participant was covered under previous
coverage, if the previous coverage was similar to or exceeded the coverage provided
under this Plan and the previous coverage was continuous to a date not more than 62
days prior to the participant's effective date of coverage under this Plan, exclusive of
any waiting period under this Plan.
The eligible participant may prove periods of prior health coverage by providing a
certificate of creditable coverage, which includes periods of coverage and benefit
coverage levels.
No pre-existing limitation will apply for an eligible participant presenting a certificate
of creditable coverage indicating continuous coverage similar to or exceeding the
coverage provided under this Plan, if the previous coverage was more than 12 months
with no more than a 62 break in coverage prior to the participant's effective date of
coverage under this Plan, exclusive of any waiting period under this Plan.
SECTION XI-TIME OF PAYMENT, GRACE PERIOD
All contributions are due and payable on the fIrst day of each month for which
coverage under this Plan is provided. If the employer fails to pay the contributions to
the Trust within twenty (20) days after they become due and payable, the Plan is
automatically terminated effective the fIrst day of the month in which such
contributions were due and payable; no participant shall thereafter be entitled to any
further benefits hereunder.
In the event this Plan terminates for any reason, the employer shall be liable for all
contributions due and unpaid as of the date of termination in the event that claims
were paid after the contributions became due and payable.
The Trust must give an employer forty-five (45) days written notice of any change in
the monthly rate of contribution or any changes in this Plan's terms or benefits.
SECTION XII - CONDITIONS FOR RENDERING SERVICE
The participant shall present proper identification issued by the Trust when applying
for hospital, physician,. pharmacy or other medical services covered under this Plan.
The Plan does not cbnfer upon the Trust or any hospital any rights to select a
physician for the participant. The participant shall be at liberty to elect his or her
"Unless Qthp.rwI~ rtated In ltl" <;':t",<l"I" 'If q",""Ilk '7 IqA\
"..-.~"'..
Rorlda Municipal Insurance Trust
Medical Master Plan of Beneflts
physician, provided such physician is acceptable for practice in the hospital to which
the participant is admitted. Nothing contained herein shall interfere with the ordinary
relationship between the participant and the physician selected by the participant.
Some employers may elect to make special arrangements with specific providers
andjor Preferred Provider Networks. If an employer makes such an arrangement, the
arrangement must be submitted to the Trust and benefits under such an ,agreement
will be paid on such terms and conditions as are agreed to in writing by the employer
and the Trust.
The Trust does not undertake to furnish any services, but merely to pay for services to
the participant to the extent herein specified. The Trust shall not, in any event, be
liable for any negligence, misfeasance, nonfeasance, malfeasance, malpractice or any
act of commission or omission on the part of any physician, hospital or other service
provider or the agent or employee of any physician, hospital or other service provider.
SECTION XIII - EMPLOYER'S TERMINATION AND RENEWAL
Except as provided in Section XI, this Plan may be terminated by either party hereto
by giving not less than forty-five (45) days written notice of termination to the other.
This Plan shall continue in force from month to month unless terminated pursuant to
the foregoing provision.
Except as hereafter provided, coverage for all employees and their dependents covered
under this Plan shall automatically terminate immediately on the earliest of the
following dates:
(1) On the date coverage under this group plan with an employer is terminated.
(2) , On the expiration date as provided in Section XI, if the employer fails to make
the required contributions.
All claims must be submitted no later than ninety (90) days after the date of
termination of the policy in order to be eligible for payment.
SECTION XIV - PARTICIPANT'S TERMINATION OF COVERAGE
Unless a participant qualifies for and elects continuation of coverage pursuant to and
in the manner provided in Section XV of the Plan:
(1) Coverage for any participant shall terminate automatically at the end of the
month for which payment of the contributions specified herein shall have
been made by the employer for such participant, In the event the employer
notifies the Trust that the coverage of such participant under this Plan is to
be terminated,
(2) Coverage of the spouse of an employee shall automatically cease upon a legal separation
of the spouse and employee or termination of the marriage between the spouse and
employee.
,
(3) Coverage of the spouse and dependents of an employee shall automatically cease upon
the death' of the employee.
(4) Coverage of a dependent child of an employee shall automatically cease as
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0..010 ?~
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
provided under Section I - Dependent.
(5) Coverage of the employee, and spouse and dependents of an employee shall
automatically cease upon the employee becoming entitled to the benefits
provided under the Title XVIII of the Social Security Act (Medicare).
(6) Subject to the provisions of Paragraphs (1) and (2) of Section III, the coverage
of any participant shall terminate automatically when the maximum benefits
for which such participant is eligible have been paid. Coverage for any
remaining family participants shall, unless otherwise terminated in
accordance with provisions hereof, continue so long as payment of required
contributions is timely made.
A certificate of creditable coverage will be issued to all participants whose coverage
terminates. The certificate will be sent by First Class Mail to the participant's last
known address. In addition, the Trust shall issue a certificate of credible coverage to
a participant upon request, for up to 24 months following the end of the participant's
coverage under this Plan.
Conversion Privilee:e on Termination of Eligibility
(1) A participant whose coverage under this Plan is terminated for any reason
and who has been validly and continuously covered under this Plan for at
least three (3) months immediately prior to such termination shall be entitled
to purchase a converted policy. The participant must apply to the Trust for
the converted policy in writing and must pay the first premium attributable
to the converted policy within thirty-one (31) days of the date of termination,
The premium for such policy will be determined with premium rates
applicable to the age and class of risk of each participant that is to be covered
under the policy and to the type and amount of coverage provided, however,
in no event shall such premium exceed 200 percent of the standard risk rate
as established by the Florida Comprehensive Health Association, adjusted for
differences in benefit levels and structure between the converted policy and
the policy offered by the Florida Comprehensive Health Association. The
converted policy will be issued without evidence of insurability and will be
effective on the day following the termination of coverage under this Plan.
(2) A participant is not entitled to a converted policy:
(a) If termination is the result of the participant or employer's failure to
timely pay a required contribution.
(b) If any discontinued coverage under this Plan is replaced by similar group
coverage within thirty-one (31) days of the date of termination of this Plan.
(c) If the participant is covered or eligible to be covered by Medicare.
(d) If the person is covered or eligible to be covered under a group policy or
similar benefits are available to the participant under state or federal law,
and the coverage or benefits, when combined with the benefits of the
converted policy, will result in the participant's overinsurance.
(3) The terms and coverage conditions in and benefits provider under the
converted policy will be designed to comply with S. 627.6675, F.S., and the
terms of S. 627.6675, F.S., shall prevail to the extent of any conflict with the
terms of this 'Plan.
(4) The converted policy may be issued by an authorized insurer selected by the
Trust to provide conversion coverage.
· .Unless otherMse stated In the Schedule of Benefits (7/98)
Page 27
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
SECTION XV - CONTINUATION OF COVERAGE - COBRA
The Plan provides an election for continuation of coverage to qualified beneficiaries
who would otherwise lose coverage under the Plan as a result of a qualifying event.
A qualified beneficiary means the covered spouse or dependent child of .a, covered
employee who is a participant in the Plan on the day before the qualifying event. In
the case of termination, the term also includes the covered employee. One exception
to this rule is when a child is born to (or placed for adoption with) an employee during
the COBRA continuation period. These children will receive all rights of a qualified
beneficiary throughout the COBRA continuation period.
A qualifying event means the occurrence of any of the following events, which would
result in the loss of coverage to:
(1) Employee:
(a) Termination of employment for any reason other than gross misconduct.
(b) Reduction of work hours.
(2) Spouse:
(a) Termination of employee's employment.
(b) Reduction of employee's work hours.
(c) Death of employee.
(d) Divorce or legal separation from employee.
(e) Employee becomes enrolled in Medicare.
(f) A covered dependent child ceases to be a dependent under the Plan.
(3) Dependent:
(a) Termination of employee's employment.
(b) Reduction of employee's work hours.
(c) Death of employee.
(d) Divorce or legal separation from employee.
(e) Employee becomes enrolled in Medicare.
(f) Dependent child ceases to be an eligible dependent as defmed by the
Plan.
Continuation of coverage is conditioned upon satisfaction of the following notice
requirements. The notice requirement relating to election coverage by qualified
beneficiaries is as follows:
(1) In the event of an employee's death, termination of employment or Medicare
eligibility, the employer shall notify the Trust within thirty (30) days of such
event. Upon receipt of notice, the Trust shall, within fourteen (14) days,
notify the qualified beneficiary of his/her right to elect continuation coverage
under the Plan.
(2) In the event of divorce, legal separation or a dependent child ceasing to
qualify a~ a dependent under the Plan, the employee or the qualified
beneficiary is required to notify the Trust within-sixty (60) days of such
qualifying event. Upon receipt of notice, the Trust shall, within fourteen (14)
days, notify the qualified beneficiary of hisjher right to elect continuation of
coverage under the Plan.
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Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
(3) Notice hereunder to employees or qualified beneficiaries shall be by First
Class Mail to their last known address; notice to the Trust shall be by First
Class Mail to the Board of Trustees of the Florida Municipal Insurance Trust.
A qualified beneficiary's election of continuation of coverage must be made within
sixty (60) days following notice to the qualified beneficiary. If the qualifying ~vent is
termination, the covered employee's election of continuation coverage shall be deemed
to include an election of continuation of coverage on behalf of any other qualified
beneficiary who would lose coverage under the Plan by reason of the termination. If
any other qualifying event occurs, the election of continuation of coverage by the
spouse shall be deemed to include an election of continuation coverage on behalf of
any other qualified beneficiary who would lose coverage under the Plan by reason of
the qualifying event.
The cost of coverage to the qualified beneficiary shall be 102% of the cost of providing
coverage for such period to a similarly situated participant under the Plan to whom a
qualifying event has not occurred. In the event the qualifying event entitling the
qualified beneficiary to continuation of coverage is the covered beneficiary's disability
as defined by the Social Security Act, the cost of coverage to the qualified beneficiary
for any month after the 18th month of continuation coverage following the date of
termination shall be 150% of the cost of providing coverage for such period to a
similarly situated participant under the Plan to whom the qualifying event has not
occurred. The cost of coverage shall be paid directly to the employer in monthly
installments.
In the event of a covered employee's termination, the period of continuation of
coverage IS:
(l) Up to eighteen (18) months from the date of said termination for such
employee and the employee's qualified beneficiaries.
(2) Up to thirty-six (36) months from the date of employee's death, divorce, or
legal separation for such employee's covered surviving spouse, divorced
spouse, legally separated spouse and such employee's covered dependents.
(3) Up to thirty-six (36) months from the date a covered dependent child ceases
. to be covered as an eligible dependent under the Plan. -
(4) Up to thirty-six (36) months from the date the covered employee becomes
entitled to Medicare benefits for the employee's covered spouse and
dependents.
(5) Up to twenty-nine (29) months from the date of such termination for such
employee and such employee's qualified beneficiaries, if it is determined,
under Title II or XVI of the Social Security Act, the covered employee was
disabled on the date of termination. The employee must notify the Trust of
said determination within sixty (60) days of said determination and within
eighteen (18) months of the date of termination. In the event another
qualifying event occurs during the eighteen (18) months following the date of
the employee's termination, the period of continuation of coverage is up to
thirty-six (30) months from the date of termination for such employee and his
qualified b<:neficiaries. .
A qualified beneficiary's continuation of coverage shall cease on the earliest of the
"Unless otherwise stated In the Schedule of Benefits (7/98)
Page 29
Ronda Municipal Insurance Trust
Medica' Master Plan of Beneflts
following:
(1) The maximum coverage period date allowed for the qualifying event;
(2) The date on which the employer ceases to provide any group health plan to
all employees;
(3) As provided in Section XI, if the qualified beneficiary fails to pay
contributions within thirty (30) days after they become due;
(4) The date the qualified beneficiary becomes covered under another group
health plan (as an employee or otherwise) with similar coverage, which does
not contain any exclusions or limitations for pre-existing conditions;
(5) The date the qualified beneficiary becomes entitled to Medicare benefits;
(6) If the coverage period is twenty-nine (29) months and the employee ceases to
be totally disabled, on the first day of the month within the coverage period
that begins more than eighteen (18) months after the date of termination and
is more than thirty (30) days after the date on which the employee ceased to
be totally disabled under Title II or XVI of the Social Security Act. However,
in no event shall the coverage period extend beyond twenty-nine (29) months
from the date of termination. Notwithstanding the above, in no event shall
said coverage extend beyond the twenty-nine (29) month coverage period.
A certificate of creditable coverage will be issued at the end of the continuation of
coverage period. The certificate will be sent by First Class Mail to the participant's last
known address. In addition, the Trust shall issue a certificate of credible coverage to
a participant upon request, for up to 24 months following the end of the participant's
coverage under this Plan.
If COBRA is elected and the eighteen (18) or thirty-six (36) months maximum time
frame is exhausted, the qualified beneficiary may be eligible for coverage under an
individual plan (through an insurer of their choice) on a guaranteed issue basis
without any pre-existing condition limitations.
In the event the Plan offers a conversion privilege, the qualified beneficiary shall be
entitled to said conversion privilege provided the qualified beneficiary applies for such
conversion plan during the last 180 days of the period of continuation coverage.
Coordination of Benefits with other plans for COBRA recipients will follow current
National Association of Insurance Commissioners (NAIC) recommendations.
SECTION XVI - PRESCRIPTION DRUGS
Coverage is provided for prescription medications prescribed by a physician which are
intended for use outside a hospital, skilled nursing facility or treatment facility.
Benefits will be paid at the coverage level shown on the Schedule of Benefits.
Presenting your prescription identification card each time you request a prescribed
medication will ensure that the provider knows that you are part of the plan. A
generic prescription drug will be provided unless the prescribing physician specifies a
brand name drug. .
In addition to the applicable exclusions specified in Section VIII, no coverage is
provided for:
Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
(1) Drugs related to a course of treatment excluded, or a condition limited under
the Plan.
(2) Injectable products and syringes (other than insulin and insulin syringes).
(3) Prescription Vitamins.
(4) Nicorette Gum, Nicotine patches such as Habitrol, ProStep, Nicoderm.
(5) Viagra and other similar virility enhancement drugs.
(6) Rogaine and other similar medications for baldness.
(7) Anorexics (appetite depressants such as "diet pills").
(8) Diabetic Test Strips and glucometors.
(9) Over the Counter medications and supplies.
(lO) Over the Counter Vitamins.
(11) Drug prescriptions of thirty (30) or more days' duration.
A Prescription Mail Program is available to meet the maintenance drug prescription
needs of a participant. Only maintenance drug prescriptions of over thirty (30) days
and less than ninety-one (91) days' duration are eligible for this program, No coverage
is provided for the exclusions specified in Section VIII, and Items (1) through (10)
listed above.
SECTION XVII - GENERAL PROVISIONS
The Trust will issue to the employer for delivery to each participating employee
covered hereunder, a Schedule of Benefits, a copy of this Plan and appropriate
identification cards, which the employee or eligible covered dependents can present to
a hospital, physician or other service provider in claiming benefits due under this
Plan. It shall be the employer's responsibility to disseminate to the eligible employee
the Schedule of Benefits, a copy of this Plan and the appropriate identification cards.
The employee's benefits are non-assignable prior to a claim. If any amendment to this
Plan shall materially affect any benefits, the amendment, a new Schedule of Benefits
and an updated copy of this Plan shall be delivered to the participating employer to be
distribute.d to employees. The Trustees shall provide benefits that are designed to
meet the needs of the participants and that are based on actuarial soundness. Tbe
Plan may be modified or discontinued by the Trustees at any time. Notices of
modification or discontinuance shall be mailed to the employer's last known address
at least forty-five (45) days prior to the effective date of such modification or
discontinuance.
All statements made by employers or the employees of such employers shall be
deemed representations and not warranties and no statement made for the purpose of
effecting coverage shall void such coverage or reduce benefits unless contained in a
written instrument signed by the employer or employee of such employer, a copy of
which has been furnished to such employer or employee as the case may be.
No reduction in benefits shall be made by reason of change in the occupation of any
employee while in the employ of the employer or by reason of the employee's doing
any act or thing pertaining to any other occupation, except as otherwise provided in
Section VI.
No representative has authority to change this Plan or waive any of its provisions. No
..Unless otherwise stated In the Schedule of Benefits (7/98)
Pae:e 31
Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
change in this Plan shall be valid unless approved by the Board of Trustees.
Written proof of claim for services shall be furnished to the Trust within 365 days
after the date of such services.
Benefits provided in this Plan will be payable to the hospital, physician or other
service provider rendering service under this Plan or to the participant upon receipt,
by the Trust, of paid bills in acceptable form.
No action at law or in equity shall be brought to recover under this Plan prior to the
expiration of sixty (60) days written notice to the Trust. No such action shall be
brought after the expiration of the specified statute of limitations on such action.
Such notice to the Trust shall be sufficient if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
135 E. Colonial Drive
Orlando, Florida 32801
An employee applying for coverage under this Plan for himself/herself or eligible
dependents and the participant and/ or each dependent of the participant agrees that,
as a condition of payment of benefits, services and supplies, any hospital, physician
or other service provider that has made or may hereafter make a diagnosis, render
service, attendance or treatment of or to a participant, may furnish and is authorized
to furnish to the Trust at any time upon its request, a report containing all
information and records or copies of records pertaining to diagnosis, attendance,
service or treatment. The applicant or participant and/or each dependent of the
applicant or participant agrees as a condition of payment of benefits or services, to
execute such medical authorization as may be required by the Trust.
The Trust' shall not be responsible for the payment of any expense for services or
supplies not covered by this Plan or any amounts in excess of the maximum benefits
allowed by this Plan.
Eligible new participants may be added to the Plan in accordance with the terms and
conditions of the Plan.
No otherwise eligible employee or dependent of a participating employer shall be
refused covera~e or be charged an unfairly discriminatory rate for participation solely
because such employee or dependent is mentally or physically handicapped; provided,
however, nothing in this Plan shall be construed to require the Trust to provide
coverage against a handicap which the applicant sustained on or before the
applicant's effective date of coverage.
In the event coverage under this Plan is conditioned upon a certain event or
condition, or conditioned upon the continuation of a certain event or condition, the
burden is on the participant to establish the existence of such event or condition or
the continuation of such event or condition.
.
To the extent of any conflict, the express words and language in this Plan will prevail
over any oral or written communications to or by the Trust concerning the terms and
conditions expressed in this Plan and such communications are hereby deemed to be
modified to reflect the terms and conditions in this Plan in the event such conflict
Ronda Municipal Insurance Trust
Medical Master Plan of Beneflts
arises. The burden is on the applicant or participant to make complete and accurate
representations to the Trust concerning questions of eligibility, coverage and services
or benefits under this Plan.
SECTION XVIII - PAYMENT OF BENEFITS, ASSIGNMENT
Benefits provided under this Plan for a specified injury or sickness may be paid to the
participant or to the service provider who has provided or paid for services or supplies
for which such benefits are payable. Such benefits may be assigrled by the
participant to such provider and will be paid according to the participant's
designation on the claim form, but only to the extent such provider's interest shall
appear; otherwise this Plan and such benefits are non-assignable. If benefits are paid
prior to the receipt and acceptance by the Trust of any assignment of such benefits,
the assignment shall be null and void and unenforceable against the Trust.
In the event an employee or dependent dies, or is physically, mentally or otherwise
incapable of making payment due to a service provider, Plan benefits may be paid
directly to the service provider or to any person or institution appearing to assume
responsibility for the expense, and such payment shall discharge the Trust's
obligation for such expense.
SECTION XIX - GRIEVANCE PROCEDURE
There are situations when participants have questions about their coverage or are
dissatisfied with Plan services. Such inquiries and complaints will be handled in a
timely manner.
In the event that a claim is denied and the participant disagrees with the denial, a re-
determination may be requested in writing detailing the reasons for the disagreement,
This request must be received within sixty (60) days of the initial claim denial. The
Plan will respond with a written decision, within sixty (60) days from receipt of- the
request.
SECTION XX - SUBROGATION
In the event of any payment for benefits, services or supplies provided to a participant
under the Plan, the Trust, to the extent of such payment, shall be subrogated to all
rights of recovery such participant has against any person or organization, and the
participant, as a condition precedent to the payment for any benefits, services or
supplies otherwise payable under this Plan, shall execute and deliver such
instruments and papers as may be required and do whatever else is necessary to
secure such rights to the Trust and shall otherwise assist and cooperate with the
Trust as may be necessary in its efforts to recover such payment.
Rorlda Municipal Insurance Trust
Medical Master Plan of Benefits
SECTION XXI - NOTICE
Notice to an employer given under the Plan shall be sufficient if given to the employer
when addressed to its office stated in the Participation Agreement; except as
otherwise herein expressly provided, if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
135 E. Colonial Drive
Orlando, Florida 3280 1