HomeMy WebLinkAboutReso 2010-1529
RESOLUTION NO. 2010- 1 SA cL
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF
SUNNY ISLES BEACH, FLORIDA, APPROVING THE
SELECTION OF A VMED AS THE PROVIDER FOR EMPLOYEE
HEAL TH INSURANCE, LINCOLN FINANCIAL GROUP AS THE
CITY'S PROVIDER FOR DENT AL INSURANCE, LIFE
INSURANCE, ACCIDENTAL, DEATH & DISMEMBERMENT (AD
& D) INSURANCE AND LONG TERM DISABILITY INSURANCE,
AND EYE MED AS THE CITY'S PROVIDER FOR VISION CARE
FOR A ONE-YEAR PERIOD; AUTHORIZING THE CITY
MANAGER TO ENTER INTO AGREEMENTS WITH THESE
PROVIDERS, PROVIDED SAID AGREEMENTS ARE APPROVED
AS TO FORM AND LEGAL SUFFICIENCY BY THE CITY
ATTORNEY; FURTHER AUTHORIZING THE CITY MANAGER
TO DO ALL THINGS NECESSARY TO EFFECTUATE THIS
RESOLUTION; PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City of Sunny Isles Beach currently provides regular full-time and part-
time employees with primary health care through A vMed, a full-service healthcare provider; and
WHEREAS, the City's insurance broker (Brown & Brown Insurance, Inc.) issued
proposals on behalf of the City to provide for the same level of benefits; and
WHEREAS, after extensive negotiations with Brown & Brown, the City's current health
care provider AvMed, submitted a proposal at a 12% increase based on the City's claims history,
and based on that increase, City staff and Brown & Brown representatives met with
representatives from AvMed, and the consensus was to move forward with the AvMed proposal
for health insurance, at the same level of benefits (HMO and POS plans) at an increase of 12%
in rates as compared to last year, and on an annual basis the total annual premium paid for this
coverage will increase by approximately $130,000.00; and
WHEREAS, the City team and Brown & Brown recommend to continue with Lincoln
Financial Group as the City's provider for dental, life, disability and accidental death and
dismemberment (AD&D), at an increase of 27% based on a loss experience of 137%, and on an
annual basis the total annual premium paid for these coverages will increase $30,000.00, and to
continue with EyeMed for vision care; and
WHEREAS, these agreements are for a period of one (1) year with a renewal date for the
City's health, dental and other employee insurances of March 1,2010.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF THE
CITY OF SUNNY ISLES BEACH, FLORIDA, AS FOLLOWS:
Section 1. Approyal of City Commission. The City Commission hereby approves the use of
A vMed as the City's health care provider, Lincoln Financial Group as the City's provider for
RlOlO- Health Insurance Renewal (Avmed Lincoln Financial Eyemed)
Page I of2
dental, life, disability and accidental death and dismemberment (AD&D), and to continue with
EyeMed for vision care, for a one-year period, with a renewal date of March 1, 2010.
Section 2. Authorization of City Manager. The City Manager is hereby authorized to enter
into agreements with said insurance providers, provided said agreements are approved as to form
and legal sufficiency by the City Attorney.
Section 3. Further Authorization of the City Manager. The City Manager IS hereby
authorized to do all other things necessary to effectuate this Resolution.
Section 3.
Effective Date. This Resolution shall become effective upon adoption.
PASSED and ADOPTED on this 18th day of February 2010.
(. \ ,
( ,
" .
"
"'" . / \ -.,.~ : .
,',' ,AT~TEST: "
~',~~.~
':'Jane"A. Hines,.CMC, City Clerk
..... .
.
Moved by: ~c.o.. YY\~v-r,*'t\Ut:.Q
Seconded by: r.N'Y\~ \SS-I o~~ ~CC2',,J
Vote: 5-0
Mayor Norman S. Edelcup
Vice Mayor Lewis Thaler
Commissioner Roslyn Brezin
Commissioner Gerry Goodman
Commissioner George "Bud" Scholl
VYes)
~(Yes)
~Yes)
V(Y es)
~(Yes)
_(No)
_(No)
_(No)
_(No)
_(No)
R2010- Health Insurance Renewal (Avmed Lincoln Financial Eyemed)
Page 2 of2
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AvMed Health Plans
Group
Medical and Hospital Service
Contract
)
A V-GIOO-2009
MP-5319 (10/09)
)
TABLE OF CONTENTS
')
I.
GENERAL..................................................................................................................................................1
II. INTERPRETATION .................................................................................................................................. 1
III. DEFINITIONS ........................................................................................................................................... 2
IV. ELIGIBILITY ............................................................................................................................................ 8
V. ENROLLMENT....................................................................................................................................... 10
VI. EFFECTIVE DATE OF MEMBERSHlP..............................................................................................12
VII. MONTHLY PAYMENTS AND CO-PAYMENTS................................................................................. 12
)
VIII. CONVERSION ........................................................................................................................................ 13
IX. TERMINATION ...................................................................................................................................... 15
X. SCHEDULE OF BASIC BENEFITS ..................................................................................................... 21
XI. LIMITATIONS OF BASIC BENEFITS ................................................................................................ 28
XII. EXCLUSIONS FROM BASIC BENEFITS ..........................................................................................30
XIII. COORDINATION OF BENEFITS ........................................................................................................ 34
)
XIV. SUBROGATION AND RIGHT OF RECOVERy................................................................................ 36
XV. DISCLAIMER OF LIABILITY ............................................................................................................. 38
XVI. GRIEVANCE PROCEDURE ................................................................................................................. 38
XVII. J\USCELLANEOUS ................................................................................................................................44
AV-GJOO-2009
MP-5319 (10/09)
")
')
AVMED CORPORATE OFFICE
9400 S. DADELAND BLVD.
MIAMI, FL 33156-9004
AVMED MEMBER SERVICES -ALLAREAS
1-800-88 AVMED
(1-800-882-8633)
o
J\UAMI
9400 South Dadeland Boulevard
Miami, Florida 33156-9004
(305) 671-5437
(800) 432-6676
Miami-Dade
)
FT. LAUDERDALE
13450 W. Sunrise Boulevard
Suite 370
Sunrise, Florida 33323-2947
(954) 462-2520
(800) 368-9189
Broward
Palm Beach
)
ORLANDO
1800 Pembroke Drive
Suite 190
Orlando, Florida 32810
(407) 539-0007
(800) 227-4848
Lake'
Orange
Osceola
Seminole
SERVICE AREAS
GAINESVILLE
4300 N.W. 89'" Boulevard
Post Office Box 749
Gainesville, Florida 32606-0749
(352) 372-8400
(800) 346-0231
Alachua
Bradford
Citrus
Columbia
Dixie
Gilchrist
Hamilton
Levy
Marion
Suwannee
Union
JACKSONVILLE
1300 Riverplace Boulevard
Suite 640
Jacksonville, Florida 32207
(904) 858-1300
(800) 227-4184
Baker
Clay
Duval
Nassau
St. J alms
TAMPA BAY/ SOUTHWEST
FLORIDA
1511 North Westshore Boulevard
Suite 450
Tampa, Florida 33607
(813) 281-5650
(800) 257-2273
Hernando
Hills boro
Lee
Pasco
Pinellas
Polk
Sarasota
. Coverage available in the following Lake County zip codes: 34736,34711,34712,34713,34714,34715 and
34756
A V-GJOO-2009
MP-53 19 (10/09)
AvMed, Inc.
d/b/a AvMed HEALTH PLANS
')
GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT
IN CONSIDERATION of the payment of monthly prepayment subscription amounts as provided herein and of
mutual promises and benefits hereinafter described, AvMed, Inc., a Florida corporation, d/b/a AvMed Health
Plans, (hereinafter referred to as 'AvMed'), and (hereinafter referred to as 'Subscribing Group') agree as
follows:
I. GENERAL
The Subscribing Group engages AvMed, on behalf of the group health plan described herein (the 'Plan'), to
arrange for the provision of Medical Services or benefits which are Medically Necessary for the diagnosis and
treatment of Members of the Subscribing Group throtlgh a network of contracted independent physicians and
Hospitals and other independent health care providers who are not agents or employees of AvMed. See Section
15.04). AvMed, in arranging for the delivery of Medical Services or benefits, does not directly provide these
Medical Services or benefits. AvMed arranges for the provision of said services in accordance with the
covenants and conditions contained in this Contract. AvMed shall rely upon the statements of the Subscriber in
his application in providing coverage and benefits hereunder.
This Contract is not intended to and does not cover or provide any Medical Services or benefits that are not
Medically Necessary for the diagnosis and treatment of the Member. The determination as to which services are
Medically Necessary shall be rnade by AvMed subject to the terms and conditions of this Contract.
AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage
criteria are medical and pharmaceutical protocols used to determine payment of products and services and are
based on independent clinical practice guidelines and standards of care established by government agencies and
medicalJphannaceutical societies.
)
The Medical and Hospital Services covered by this Contract shaH be provided without regard to the race, color,
religion, physical handicap, or national origin of the Mernber in the diagnosis and treatment of patients; in the
use of equipment and other facilities; or in the assignment of personnel to provide services, pursuant to the
provisions of Title VI of the Civil Rights Act of 1964, as amended, and the Americans with Disabilities Act of
1990.
II. INTERPRETATION
In order to provide the advantages of Hospital and medical facilities and of the Participating Providers, AvMed
operates on a direct service rather than indemnity basis. The interpretation of this Contract shaH be guided by
the direct service nature of AvMed's program and the definitions and other provisions contained herein..
I
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n
)
III. DEFINITIONS
10
As used in this Contract, each of the following terms shall have the meaning indicated:
3.01 Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or
failure to provide or make payment that is based on a determination of a Member's eligibility to
participate in the Plan, and including a denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for, a benefit resulting from the application of any Utilization
Management Program, as well as a failure to cover an item or service for which benefits are otherwise
provided hecause it is deteffilined to be experimental and/or investigational or not Medically Necessary.
3.02 Applied Behavior Aoalysis means the design, implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences, to produce socially significant improvement
in human behavior, including, but not limited to, the use of direct observation, measurement, and
functional analysis of the relations between environment and behavior. Applied behavior analysis
services shall be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an
individual licensed under Chapter 490 or Chapter 491, Florida Statutes.
3.03 Attending Physician means tbe Participating Physician primarily responsible for the care ofa Member
with respect to any particular injury or illness.
3.04 Autism Spectrum Disorder means any of the following disorders as defined in the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:
)
3.04.01
3.04.02
3.04.03
Autistic disorder;
Asperger's syndrome;
Pervasive developmental disorder not othenvise specified.
3.05 AvMed, Inc. othenvise known as 'AvMed', means a private not for profit Florida corporation, state
licensed as a health maintenance organization under Chapter 641, Florida Statutes, for the purpose of
arranging for prepaid health care services to its Members under the terms and conditions set forth in this
Contract.
3.06 Claim means a request for benefits under this Contract made by a Mernber in accordance with AvMed's
procedures for filing benefit claims, including Pre-Service Claims and Post-Service Claims.
3.07 Claimant means a Member or a Mernbcr's authorized representative acting on behalf of the Member.
AvMed may establish procedures for determining whether an individual is authorized to act on behalf of
the Member. If the Claim is an Urgent Care or Pre-Service Claim, a Health Professional, with
knowledge of the Member's medical condition, shall be permitted to act as the Member's authorized
representative and will he notified of all approvals on the Claimant's behalf. In the event of an Adverse
Benefit Determination, AvMed will notify both the Member and the Heath Professional.
3.08 Concurrent Care rneans an ongoing course of treatment to be provided over a period of time or number
of treatments that was previously approved by AvMed.
3.09 Con tract means this Group Medical and Hospital Service Contract which may at times be referred to as
'Group Contract' or 'Subscribing Group Contract' and all applications, rate letters, face sheets,
riders, amendments, addenda, exhibits, supplemental agreements, and schedules which are or may be
incorporated in this Contract from time to time.
3.10 Contract Year rneans the period of consecutive months agreed to by the Subscribing Group and AvMed
on the Master Application, commencing on the effective date of this Contract.
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)
3.11 Conversion Contract means an individual Member or Subscriber contract which shall be available to
continue coverage (as provided for therein) of the Subscriber or the Dependent of the Subscriber upon
termination of the Subscribing Group Contract as provided in Part vrn of this Contract, and shall at
times be referred to as the 'Individual Conversion Contract.'
')
3.12 Co-payment means the charge, in addition to the prepaid premium amounts, which the Subscriber is
required to pay at the time certain health services are provided under this Contract. The Co-payment
may be a specific dollar amount or a percentage of the cost. The Member is responsible for the payment
of any Co-payment charges directly to the provider oftbe health services at the time of service.
3.13 Custodial Care means services and supplies that are furnished mainly to train or assist in the activities
of daily living, such as bathing, feeding, dressing, walking, and taking oral medications. 'Custodial
Care' also rneans services and supplies that can be safely and adequately provided by persons other than
licensed health professionals, such as dressing changes and catheter care, or that ambulatory patients
customarily provide for themselves, such as ostomy care, administering insulin, and measuring and
recording urine and blood sugar levels.
3.14 Dental Care means dental x-rays, examinations and treatment of the teeth or any services, supplies or
charges directly related to:
,J
The care, filling, rernoval or replacement of teeth, or
The treatment of injuries to or disease of the teeth, gums or structures directly supporting or
attached to the teeth, that are custornarily provided by dentists (including orthodontics
reconstructive jaw surgery, casts, splints, and services for dental malocclusion).
3.15 Dependent means any member of a Subscriber's family who meets all applicable requirements of Part
IV and is enrolled hereunder and for whom the prepayrnent required by Part VII has actually been
received by AvMed.
3.14.01
3.14.02
3.16
3.16.01
Emergency Medical Condition means:
)
A medical condition manifesting itself by acute symptorns of sufficient severity such that the
absence of inunediate medical attention could reasonably be expected to result in any of the
following:
a) Serious jeopardy to the health of a patient, including a pregnant woman or fetus.
b) Serious impairment to bodily functions.
c) Serious dysfunction of any bodily organ or part.
With respect to a pregnant woman:
a) That there is inadequate time to effect safe transfer to another Hospital prior to delivery;
b) That a transfer may pose a threat to the health and safety of the patient or fetus; or
c) That there is evidence of the onset and persistence of uterine contractions or rupture of
the membranes.
Examples of Emergency Medical Conditions include, but are not limited to: heart attack,
stroke, massive internal or external bleeding, fractured limbs, or severe trauma.
3.17 Emergency Medical Services and Care means medical screening, examination, and evaluation hy a
physician, or, to the extent permitted by applicable law, by other appropriate personnel under the
supervision of a physician, to determine if an Emergency Medical Condition exists and, if it does, the
care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the
Emergency Medical Condition within the service capability ofthe Hospital.
3.16.02
3.16.03
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)
3
In-area emergency does not include elective or routine care, care of minor illness, or care
that can reasonably be sought and obtained from the Member's Primary Care Physician. The
determination as to whether or not an illness or injury constitutes an emergency shall be
made by AvMed and rnay be made retrospectively based upon all information known at the
time the patient was present for treatment.
Out-of-area emergency does not include care for conditions for which a Member could
reasonably have foreseen the need of such care before leaving the Service Area or care that
could safely be delayed until prompt return to the Service Area The determination as to
whether or not an illness or injury constitutes an emergency shall be made by AvMed and
may be made retrospectively based upon all information known at the time the patient was
present for treatment.
Exclusion means any provision of this Contract whereby coverage for a specific hazard or condition is
entirely eliminated.
Full-Time Student or Part-Time Student rneans one who is attending a recognized and/or accredited
college, university, vocational, or secondary school and is carrying sufficient credits to qualifY as a Full-
Time or Part-Time student in accordance with the requirements of the school. See Subsection
4.02.02(e).
f)
)
3.17.01
3.17.02
3.18
()
3.19
3.20 Group Health Insurance (for purposes of Part XIII) means that form of health insurance covering
groups of persons under a master Group Health Insurance policy issued to anyone of the groups listed
in Chapters 627.552 (employee groups), 627.553 (debtor groups), 627.554 (labor union and association
groups), and 627.5565 (additional groups), Florida Statutes.
3.20.01
)
3.20.02
The terms 'amount of insurance' and 'jnsurance' include the benefits provided under a plan
of self-insurance.
The term 'insurer' includes any person, entity, or governmental unit providing a plan of self-
insurance.
The terms 'policy', 'insurance policy', 'health insurance policy', and 'Group Health
Insurance policy' include plans of self-insurance providing health insurance benefits.
3.21 Health Professionals means physicians, osteopaths, podiatrists, chiropractors, physician assistants,
nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists, occupational
therapists, physical therapists, and other professionals engaged in the delivery of health care services
who are licensed and practice under an institutional license, individual practice association, or other
authority consistent with State law and who are Participating Providers of AvMed.
3.22 Home Health Care Services (Skilled Home Health Care) means services that are provided for a
Member who does not require confinement in a Hospital or Other Health Care Facility. Such services
include, but are not limited to, the services of professional visiting nurses or other health care personnel
for services covered under this Contract. A visit is limited to a period of 2 hours or less. See Section
10.28 regarding physical and occupational therapy Limitations.
3.20.03
3.23 Hospice means a public agency or private organization that is duly licensed by the State to provide
Hospice services and with whorn AvMed has a current provider agreement. Such licensed entity must
be principally engaged in providing pain relief, symptom management, and supportive services to
terminally ill Members.
3.24 Hospital means any general acute care facility which is licensed by the State and with which AvMed
has contracted or established arrangernents for inpatient Hospital Services and/or Emergency Medical
Services and Care, and shall at times be referred to as a 'Participating Hospital'.
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)
3.25 Hospital Services (except as expressly limited or excluded by this Contract) means those services for
registered bed patients that are:
Generally and customarily provided by acute care general Hospitals in accordance with the
standards of acceptable community practice;
Performed, prescribed, or directed by Participating Providers; and
Medically Necessary for conditions which carmot be adequately treated in Other Health Care
Facilities or with Home Health Care Services or on an ambulatory basis.
3.26 HospitalistJAdmitting Panelist means a physician who specializes in treating inpatients and who rnay
coordinate a Member's health care when the Member has been admitted for a Medically Necessary
procedure or treatment at a Hospital.
3.25.01
3.25.02
3.25.03
')
3.27 Injectable Medication means a medication that has been approved by the Food and Drug
Administration (FDA) for administration by one or more of the following routes: intramuscular
injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection,
intrarticular injection, intracavernous injection or intraocular injection. Pre-authorization is required for
Injectable Medications.
3.28 Limitation rneans any provision (other than an Exclusion) which restricts coverage under this Contract.
3.29 Master Application means the Subscribing Group application form entitled 'Master Application' which
becomes a part of the Contract when the Master Application has been completed and executed by the
Suhscribing Group and AvMed.
3.30 Maximum Allowahle Payment means the maxirnum amount that AvMed will pay for any covered
service rendered by a Non-participating Provider or supplier of services, medications, or supplies. The
maximurn amount that AvMed will pay for each such covered service can be found on the Maximum
Allowable Payment Schedule available at www.avrned.org.
3.31 Medically Necessary means the use of any appropriate medical treatment, service, equipment, and/or
supply as provided by a Hospital, skilled nursing facility, physician, or other provider which is
necessary for the diagnosis, care, and/or treatment of a Member's illness or injury, and which is:
3.31.0 I
3.31.02
3.31.03
3.31.04
3.31.05
3.31.06
j
)
Consistent with the symptom, diagnosis, and treatment of the Member's condition;
The most appropriate level of supply and/or service for the diagnosis and treatment of the
Member's condition;
In accordance with standards of acceptable community practice;
Not primarily intended for the personal comfort or convenience of the Member, the
Member's family, the physician, or other health care providers;
Approved by the appropriate medical body or health care specialty involved as effective,
appropriate, and essential for the care and treatment of the Member's condition; and
Not experimental or investigational.
3.32 Medical Office means any outpatient facility or physician's office in the Service Area utilized by a
Participating Provider.
3.33 Medical Services (except as limited or excluded by this Contract) rneans those professional services of
physicians and other Health Professionals, including medical, surgical, diagnostic, therapeutic, and
preventive services that are:
3.33.01
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Generally and customarily provided in the Service Area;
5
I
If)
I
I
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)
3.33.02 Performed, prescribed, or directed by Participating Providers; and
3.33.03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and
treatment of injury or illness.
3.34 Member means any Subscriber or Dependent, as described in Part Ill, Sections 3.46 and 3.15, of this
Contract.
3.35 Non-participating Provider means any Health Professional or group of Health Professionals or
Hospital, Medical Office, or Other Health Care Facility with whom AvMed has neither made
arrangements nor contracted to render the professional health services set forth herein as a Participating
Provider.
Other Health Care Faeility(ies) means any licensed facility, other than acute care Hospitals and those
facilities providing services to ventilator dependent patients, which provides inpatient services such as
skilled nursing care and rehabilitative services for which AvMed has contracted or established
arrangements for providing these services to Members.
3.36
10
3.37 Participating Provider means any Health Professional (or group of Health Professionals), Hospital,
Medical Office, or Other Health Care Facility with whom AvMed has made arrangements or contracted
to render the professional health services set forth herein.
3.38 Participating Physician means any Participating Provider licensed under Chapter 458 (physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes.
3.39 Post-Service Claim means any Claim for benefits under the Plan that is not a Pre-Service Claim.
3.40 Pre-Service Claim means any Claim for benefits under the Plan with which (in whole or in part), a
Member must obtain authorization from AvMed in advance of such services being provided to or
) received by the Member.
3.41 Primary Care Physician means a Participating Physician engaged in family practice, pediatrics,
intemal medicine, obstetrics/gynecology, or any specialty physician from time to time designated by
AvMed as a 'Primary Care Physician' in AvMed's current list of physicians and Hospitals.
3.42 Private Duty Nursing means services provided by registered nurses, licensed practical nurses, or any
other trained attendant whose services ordinarily are rendered to, and restricted to, a particular Member
by arrangements between the Member and the private-duty nurse or attendant. Such persons are
engaged or paid by an individual Member or by someone acting on their behalf, including a hospital that
initially incurs the costs and looks to the Mernber fOr reimbursement for such services.
3.43 Relevant Document means any documentation that:
3.43.01
Was relied upon in making a benefit determination;
3.43.02 Was submitted, considered or generated in the course of making a benefit determination,
without regard to whether it was relied upon in making the determination;
3.43.03 Demonstrates compliance with the Plan's administrative process; and
3.43.04 Constitutes a statement of policy or guidance with respect to the Plan conceming the
Adverse Benefit Determination for the Claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the Adverse Benefit Determination.
3.44 Self-Administered Injectable Medication means a medication that has been approved by the FDA for
self-injection and is administered by subcutaneous injection or a medication for which there are
instructions to the patient for self-injection in the rnanufacturer's prescribing information (package
insert).
6
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)
Service Area means those counties in the State of Florida where AvMed has been approved to conduct
business by the Agency for Health Care Administration (AHCA).
3.46 Specialty Health Care Physician means any Participating Physician licensed under Chapter 458
(physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, other than the
Member's chosen Primary Care Physician.
3.45
')
3.47 Subscriber means a person who meets aU applicable requirements of Section 4.01, enrolls in the Plan,
and for whom the premium prepayrnent required by Part VII has actually been received by AvMed.
3.48 Subscribing Group means a corporation, partnership, limited liability company or other legal entity
(and its wholly-owned subsidiaries) that negotiates and agrees to contract for the health services and
benefits provided herein for its eligible employees.
Total Disability means a totally disabling condition resulting from an illness or injury which prevents
the Memher from engaging in any ernployment or occupation for which he rnay otherwise become
qualified by reason of education, training, or experience, and for which the Member is under the regular
care of a physician.
3.50 Urgent Care Claim means any Claim for rnedical care or treatment that could seriously jeopardize the
Member's life or health or the Member's ability to regain maximum function or, in the opinion of a
physician with knowledge of the Member's medical condition, would subject the Member to severe pain
that cannot be adequately rnanaged without the care or treatment requested. Generally, the
determination of whether a Claim is an Urgent Care Claim shaU be rnade by an individual acting on
behalf of AvMed applying the judgrnent of a prudent layperson who possesses an average knowledge of
health and medicine. However, if a physician with knowledge of the Mernber's medical condition
determines that the Claim is an Urgent Care Claim, it shall be deemed as such.
3.49
l)
Urgent CarelImmediate Care means medical screening, examination, and evaluation received in an
Urgent Care Center or lmmediate Care Center or rendered in your Primary Care Physician's office after-
hours and the covered services for those conditions which, although not life-threatening, could result in
serious injury or disability ifleft untreated.
3.52 Utilization Management Program means those comprehensive initiatives that are designed to validate
medical appropriateness and to coordinate covered services and supplies. These include, but are not
lirnited to:
3.51
)
3.52.01
Concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and
skilled nursing facilities, including on-site review when appropriate;
3.52.02 Case management and discharge planning for all inpatients and those requiring continued
care in an alternative setting (such as home care or a skilled nursing facility) and for
outpatients when deerned appropriate; and
3.52.03 The Benefit Coordination Program which is designed to conduct .prospective reviews for
select medical services to ensure that services are covered and Medically Necessary. The
Benefit Coordination Program rnay also advocate altemative cost-effective settings for the
delivery ofpre,cribed care and rnay identifY other options for non-covered health care needs.
3.53 Ventilator Dependent Care Unit rneans care received in any facility which provides services to
ventilator dependent patients other than acute Hospital care, including all types of facilities known as
sub-acute care units, ventilator dependent units, alternative care units, sub-acute care centers, and all
other like facilities whether maintained in a free standing facility or maintained in a Hospital or skilled
nursing facility setting.
7
AV-OIOO-2009
MP-5319 (10/09)
4.01 To be eligible to enroll as a Subscriber, a person must be:
4.01.01 An employee of the Subscribing Group who works the required number of hours per week as
set forth in the Master Application for this Contract. The employee must either work or
reside in the Service Area. Except as provided for Emergency Medical Services and
Care, the covered services and benefits are available only from Participating Providers.
Employed for the period of time required for eligibility as set forth in the Master
Application; and
Entitled on his own behalf to participate in the medical and Hospital care benefits arranged
by the Subscribing Group under this Contract.
')
)
4.01.02
4.01.03
10
IV. ELIGIBILITY
To be eligible to enroll as a Dependent, a person must be:
4.02.01 The spouse ofthe Subscriber; a new spouse must be enrolled within 31 days after rnarriage
in order to be covered; or
4.02
4.02.02
)
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MP-5319 (10/09)
A child of the Subscriber, or a child of a covered Dependent of the Subscriber, provided that
all ofthe following conditions apply:
a) The child is the natural child or stepchild of the Subscriber; a legally adopted child in
the custody of the Subscriber from the time of placement in the home (written evidence
of adoption must be furnished to AvMed opon request); a child for whorn the Subscriber
has been appointed legal guardian, pursuant to a valid court order; or a newbom child
of a covered Dependent of the Subscriber (such coverage terminates 18 months after the
birth of the newborn child);
b) The child resides with the Subscriber (except for 'e' and 'g' below);
c) The child is under the age of 19 (except for 'e' and 'f' below, or Section 4.04 below);
d) The child is principally dependent upon the Subscriber for maintenance and support and
is not regularly ernployed by one or more employers for a total of 30 hours or more per
week;
e) The child, from age 19 through the end of the calendar year when the child turns 25, if
the child meets the following requirements:
I) The child is dependent upon the Subscriber for support; and
2) The child is living in the household of the Subscriber or the child is a Full- Tirne or
Part-Time Student. See Section 3.19.
3) It is the Subscriber's responsibility to notifY AvMed when the child no longer meets
these requirements. Termination of coverage may be retroactively applied if AvMed
is not notified within 31 days. Subscriber agrees to provide supporting
documentation upon request by AvMed.
4) In the event the enrolled Dependent child, who is a Full-Time or Part-time Student,
suffers frorn a serious illness or injury requiring a leave of absence from school
which would otherwise cause the Dependent child to lose eligibility under the plan,
coverage will be extended for one year from the ftrst day of the leave of absence or
the date on which coverage under the plan would otherwise terminate, whichever
occurs fIrst. AvMed will require written certifIcation from a treating physician
8
)
stating that the Dependent is suffering from a serious illness or injury and that the
leave of absence is Medically Necessary.
f) The child is age 19 or over and is wholly dependent on the Subscriber due to mental
retardation or physical handicap. See Section 4.04.
g) In the event an eligible Dependent child does not reside with the Subscriber, coverage
will be extended when the Subscriber is obligated to provide medical care by a
Qualified Medical Child Support Order. You (or your beneficiaries) may obtain,
without charge, copies of the Plan's procedures governing Qualified Medical Child
Support Orders and a sample Qualified Medical Child Support Order by contacting the
Plan Administrator.
h) In the case of a newborn child, AvMed should be notified in writing prior to the
scheduled delivery date of the Subscriber's intention to enroll the newborn child, but
such notice shall not be later than 31 days after the birth. If timely notice is provided,
no additional premium will be charged for the additional coverage of the newborn
during the 31-day period following the birth of the child. If timely notice is not
provided, the additional premium for the additional coverage of the newborn child will
be charged from the child's date of birth. If notice is not provided within 60 days of the
birth, the child may not be enrolled until the next open enrollrnent period of the
Subscribing Group.
i) All services applicahle for covered Dependent children under this Contract shall be
provided to an enrolled newborn child of the Subscriber or to the enrolled newborn
child of a covered Dependent of the Subscriber or to the newborn adopted child of the
Subscriber provided that a written agreement to adopt such child has been entered into
(prior to the birth of the child) from the moment of birth (as provided in Part X, Section
10.18). In the case of the newborn adopted child, however, coverage shall not be
effective if the child is not ultimately placed in the Subscriber's residence in cornpliance
with Florida law.
')
1
)
j) Coverage for the newborn child of a covered Dependent of the Subscriber (other than
the spouse of the Subscriber) shall terminate 18 months after the birth of the newborn
child.
In the event the Subscriber has a child, extended coverage inay be available for that child
until the end of the calendar year in which the child reaches age 30, if the child meets the
following requirements:
a) The child is unmarried and does not have a Dependent of his or her own;
b) The child is a resident of Florida or a Full-Time or Part-Time Student; and
c) The child is not provided coverage as a named Subscriber, insured, enrollee or covered
person under any other group, blanket, or franchise health insurance policy or
individual health benefits plan, or is not entitled to benefits under Title XVIII of the
Social Security Act.
d) The child is not eligible to be covered unless the child was continuously covered by
other creditable coverage without a gap in coverage of more than 63 days.
4.03 No person is eligible to enroll hereunder who has had his coverage previously terminated under Part IX,
Subsection 9.01.05, except with the written approval of AvMed.
4.02.03
4.04 Attainment of the limiting age by a Dependent child shall not operate to exclude from or terminate the
coverage of such child, while such child is and continues to be both:
9
A V-G 1 00-2009
MP-5319 (10/09)
f)
)
Incapable of self-sustaining employment by reason of mental retardation or physical
handicap; and
Chiefly dependent upon the Subscriber for support and maintenance, provided proof of such
incapacity and dependency is furnished to AvMed by Subscriber within 31 days of the child's
attainment of the limiting age and subsequently as may be required by AvMed, but not more
frequently than arrnually after the 2-year period following the child's attainment of the
limiting age.
4.05 During the term of this Contract, no changes in the Subscribing Group eligibility or requirements of
participation shall be permitted to effect eligibility or enrollment under this Contract unless such change
is agreed to by AvMed.
4.04.02
4.04.01
4.06 Eligible persons must reside within the continental United States, excluding Alaska and Hawaii.
10
V. ENROLLMENT
5.01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof, AvMed
may allow an open enrollment period of 31 days, in which any eligible employee on behalf of himself
and his Dependents may elect to enroll in the Plan.
5.02 Except as provided for newborns, eligible employees and Dependents who meet the requirements of
Part IV, Sections 4.01 and 4.02 must enroll within 31 days after becorning eligible by subrnitting
application forms acceptable to or provided by AvMed; otherwise, the eligible employees and
Dependents rnay not enroll until the next open enrollrnent period of the Subscribing Group.
) 5.03 Special enrollment periods
5.03.01 An eligible ernployee or Dependent may request to enroll in the Plan outside of the initial
enrollrnent period and annual open enrollment periods if that individual loses other coverage
or acquires a new dependent as outlined below:
a) If the eligible employee or Dependent declined coverage under the Plan when it was
first offered because of other group health plan coverage or insurance coverage and
such coverage has terminated as a result of:
1) Exhaustion of COBRA continuation coverage;
2) Termination of employrnent or reduction in hours of ernployment;
3) Termination of employer contributions;
4) Legal separation, divorce or annulrnent;
5) Change in Dependent status;
6) Death of an employee;
7) Change in legal custody or legal guardianship;
8) Relocation out of an HMO Service Area;
9) Attainment oflifetime rnaxirnum.
b) If the eligible employee or Subscriber acquires a new Dependent as a result of:
I) Marriage;
10
A V -01 00-2009
MP-5319 (10/09)
2) Birth;
3) Adoption or placement for adoption;
c) The eligible employee, Subscriber or Dependent must complete and subrnit an
Enrollment or Status Change form within 31 days of the termination of other coverage
and provide proof of continuous coverage under the other plan; or within 31 days of the
date the Dependent becomes eligible (or within 60 days as required for newborns). If
an employee is eligible but not enrolled, the ernployee will also be required to enroll at
this time.
Employees and their Dependents who are eligible for coverage but not enrolled, shall be
eligible to enroll for coverage within 60 days following:
a) Termination of coverage under Medicaid or Children's Health Insurance Plan (CHIP)
due to loss of eligibility; or
b) Deternllnation of eligibility for premium assistance under Medicaid or CHIP.
c) The ernployee or Dependent must complete and subrnit an Enrollment or Status Change
form within 60 days of the date of the loss of Medicaid or CHIP coverage, and within
60 days of the determination of eligibility for prernium assistance under Medicaid or
CHIP. If an employee is eligible but not enrolled, the employee will also be required to
enroll at this time in order to cover an eligible Dependent.
Termination resulting from failure to pay premiums on a timely basis or termination of
coverage for cause (due to fraud, intentional misrepresentation, etc.) will not provide a
special enrollment period.
5.04 The eligibility requirements set forth in Part IV shall at all times control and no coverage contrary
thereto shall be effective. Coverage shall not be implied due to clerical or administrative errors if such
coverage would be contrary to Part IV. See also Section 17.05)
5.03.02
5.03.03
)
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5.05 This Contract, at the sole option of AvMed, will not be accepted if at the time of initial offering to
Subscribing Group or, following re-enrollment, the total enrollrnent does not result in a predetermined
minirnum enrollment as established by AvMed. The required rninimum group enrollment is included in
the rate letter submitted to Subscribing Group.
A V -0 100-2009
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II
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)
VI. EFFECTIVE DATE OF MEMBERSHIP
)
Subject to the payment of applicable monthly premium charges set forth in Part VII and to the provisions of this
Contract, coverage under this Plan shall become effective on the following dates:
6.0 I Eligible employees, Subscribers and Dependents who enroll during the open enrollment period will be
covered Members as of the effective date of this Contract or subsequent anniversary thereof.
6.02 If a Subscriber acquires an eligible Dependent through birth, adoption, placement for adoption or
rnarriage, such Dependent shall be treated as covered under the Plan if, within 31 days (or as otherwise
provided for newborns in Part IV) of acquiring the new Dependent, you complete and submit an
enrollment form on behalf of such Dependent. If received by AvMed within the 31 day time period (or
60 days as permitted for newborns), the enrollment for such Dependent shall become effective on the
date of the birth, adoption or placement for adoption, or in the case of marriage, on the first day of the
month following the date of marriage. During this period, you and your eligible spouse may also enroll
for rnedical coverage under the Plan if not already covered. However, if an enrollment request is not
received by AvMed within the required time frame, you and your eligible Dependents will be required
to wait until the next open enrollment period to apply for coverage.
6.03 Coverage for the newborn child of the Subscriber or the newborn child of the Subscriber's covered
Dependent is effective at birth if Subsection 4.02.02(i) and Section 6.02 are complied with.
6.04 If you or your Dependents originally declined medical coverage under the Plan due to other health
coverage, and that coverage is subsequently terminated as a result of either a loss of eligibility for such
coverage or the termination of any employer contributions for such coverage, you and your Dependents
will be eligible to enroll in the Plan. To enroll, you must complete and submit an Enrollment form
within 31 days of the loss of such other coverage or the termination of employer contributions. The
effective date of any coverage provided by AvMed will be the first day of the month following the date
you euroll. If you fail to enroll within 31 days after the loss of other coverage, you and your eligible
Dependents must wait until the next open enrollment period to apply for coverage.
6.05 If you or your Dependents are eligible for coverage but not enrolled, and experience a termination of
coverage under Medicaid or CHIP due to loss of eligibility, or are determined to be eligible for premium
assistance under Medicaid or CIDP, you and your Dependents will be eligible to enroll in the Plan. To
enroll, you must complete and submit an enrollment form within 60 days ofthe loss of such coverage or
the determination of such eligibility. The effective date of any coverage provided by AvMed will be the
first day of the month following the date you enroll. If you fail to enroll within 60 days after the loss of
such coverage or the determination of such eligibility, you and your eligible Dependents must wait until
the next open enrollment period to apply for coverage.
o
VII. MONTHLY PAYMENTS AND CO-PAYMENTS
7.0 I On or before the fIrst day of each month for which coverage is sought, Subscribing Group or its
designated agent shall remit to AvMed, on behalf of each Subscriber and his Dependents, the monthly
premium based on the rate letter and Master Application. Only Members for whom the stipulated
payrnent is actually received by AvMed shall be entitled to the health services covered under this
Contract and then only for the period for which such payment is applicable. Failure of the Subscribing
Group to pay the premium due by the first of the month and not later than the end of the grace period (as
provided in Section 7.02) shall result in retroactive termination of the Subscribing Group, effective at
12:00 a.m. (midnight) on the last day of the month for which the premium was paid, unless the payment
of premiums has otherwise been contractually adjusted and specified by the parties in a fully executed
12
A V-GI00-2009
MP-53 19 (10/09)
1
addendum to this Contract. An additional charge will apply to all late premium payrnents. See Section
17.17
)
7.02 Grace period. This Contract bas a ten-day grace period. This provision means that if any required
premium is not paid on or before the date it is due, it must be paid during the following grace period.
During the grace period, the Contract will stay in force. However, if payment is not received by the last
day of the grace period, termination of this Contract for nonpayment of the premium will be retroactive
to 12:00 a.m. (midnigbt) on the last day of the month for which the premium was paid. Note: Certain
provisions in Section 7.01 may apply if the parties have executed an addendum affecting premium
payments.
7.03 Maximurn Co-payments. Total annual Co-payments are limited as described in your Schedule of
Benefits. The Co-payment limits apply to Co-payments made for all core benefits contained in this
Contract, and do not apply to services provided under the Prescription Medication, Vision and other
amendments.
7.04 Member shall pay premiums, applicable supplernental charges, or Co-payments as provided in this
Contract and applicable Schedule of Benefits. Ifthe Member fails to pay the applicable premiums, upon
10 days written notice from AvMed to the Member, the Member's rights hereunder shall be terminated.
Consideration for reinstaternent with AvMed shall require a new application, and any re-enrollrnent shall
be at the sole discretion of AvMed and shall not be retroactive.
7.05 Refund of premiums paid to AvMed by the Subscribing Group for any Member after the date on which
that Member's eligibility ceased or the Member was terminated shall be limited to the total excess
premium amounts paid up to a maximum of 60 days from the date of such ineligibility or termination,
provided there are no Claims incurred subsequent to the effective date of termination.
No retroactive terminations of Members will be made heyond 60 days from notification of the
terminating event.
7.06 In the event of the retroactive termination of an individual Member (as described in Subsections 9.01.02
and 9.02.01 of this Contract), AvMed shall not be responsible for medical expenses incurred by AvMed
in providing benefits to the Member under the terms of this Contract after the effective date of
termination (due to the Subscribing Group's nonpayment of premiums or failure to tirnely notifY AvMed
of Member ineligibility). At the discretion of AvMed, and based on tbe facts availahle at the time,
AvMed may pursue either the Subscribing Group or the Member for payment.
_I
)
VIII. CONVERSION
8.0 I A Subscriber or covered Dependent whose coverage under the Subscribing Group Contract has been
terminated for any reason, including discontinuance of the Subscribing Group Contract in its entirety or
with respect to a covered class, and who has been continuously covered under the Subscribing Group
Contract, and under any group health maintenance contract providing similar henefits which it replaces,
for at least 3 months inunediately prior to termination, shall be entitled, subject to the exceptions
contained herein, to have issued to hirn or her a Conversion Contract (see Section 3.11), unless there is a
replacement of discontinued group coverage by sirnilar group coverage within 31 days.
8.01.01
The converting Subscriber and each of the eligible Dependents of the Subscriber who are
converting must be Members of the Plan in good standing on the date when their coverage
terminates under this Group Contract, and all such Subscribers and Dependents, after
cornplying with Subsection 8.01.02 below, shall be covered under the Individual Conversion
Contract.
13
A V -Gl 00-2009
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")
')
CJ
)
8.01.02 A completed Status Change form requesting conversion shall be sent to AvMed or its
designated administrator with the Erst applicable premium and shall be received by AvMed
or its designated administrator not later than 63 days after the date of termination of this
Group Contract.
8.01.03 Dependents may not convert without the Subscriber except:
a) In the event of the death of the Subscriber, Dependents are permitted an automatic
conversion privilege and must comply with Subsection 8.01.02 above.
b) A spouse whose coverage would terminate, or a spouse and children whose coverage
would otherwise terminate at the same time, or a child with respect to himself, by
reason of ceasing to be a qualified family member, rnay convert and must cornply with
Subsection 8.01.02 above.
c) A former spouse whose coverage would otherwise terminate because of annulment or
dissolution of marriage may convert if the former spouse is dependent for [mancial
support. The former spouse must comply with Subsection 8.01.02 above and must
provide written evidence of financial dependence upon request of AvMed.
8.01.04 Payment for health care services rendered to a Member after termination and prior to
conversion shall be the responsibility of the Mernber. When the conversion application has
been timely completed (within 63 days after termination of the Group Contract) and the first
premium due has been paid, AvMed shall reimburse the Subscriber for any payment made by
the Subscriber for covered Medical Services under the converted Contract.
8.01.05 A new Conversion Contract is established upon application and payrnent of the premium on
the day following the Member's termination from group coverage (due to ineligibility under
the Group Contract) and continues through the end of the calendar year. The Contract Year,
upon renewal, shall be the calendar year.
8.01.06 Individual Conversion Contracts may not include supplemental benefits, notwithstanding the
supplemental benefits included under this Subscribing Group Contract, and may in other
respects, as determined by AvMed, differ from this Group Contract.
8.01.07 The conversion privilege will not apply to a Subscriber or covered Dependent if termination
of coverage under this Contract occurred for any of the following reasons:
a) Failure to pay any required premium or contrihution unless such nonpayment of
premium was due to acts of an employer or person other than the individual;
b) Replacement of any discontinued group coverage by similar group coverage within 31
days;
c) Fraud or material misrepresentation in applying for any benefits under this Contract
(see Subsection 9.01.05);
d) Willful and knowing misuse of AvMed's identification card by the Member;
e) Willfully and knowingly furnishing incorrect or incornplete information to AvMed for
the purpose of fraudulently obtaining coverage or benefits from AvMed; or
f) Termination from coverage under this Contract in accordance with Subsection 9.01.05.
8.02 Conversion after Continuation Coverage. When continuation coverage as provided under the
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) expires, the
Subscriber or covered Dependent may be eligible for conversion coverage and may apply by completing
an application for an Individual Conversion Contract, subject to the conditions described in this Part
14
AV-0100-2009
MP-5319 (10/09)
1
VIII. The eligible Subscriber or Dependent must send a completed application and the applicable
premium payment, postmarked not later than 63 days after the termination of COBRA coverage, directly
to:
8.02.01
8.02.02
')
AvMed
Accounts Receivable
Department
Suite 510
9400 South Dadeland Blvd.
Miami, Florida 33156
The Subscriber or Dependent may obtain an application form and a statement of current
premium rates for the Individual Conversion Contract by calling AvMed Member Services.
It is the responsibility of the Subscribing Group to notify Subscriber of Subscriber's rights
under COBRA. For any specific questions concerning COBRA, contact the Subscribing
Group.
L)
IX. TERMINATION
All rights and benefits under this Contract shall cease as of the effective date of termination, unless otherwise
provided herein.
This Contract shall continue in effect for one year from the effective date hereof and may be renewed from year
to year thereafter, subject to the following termination provisions. All rights to benefits under this Contract shall
cease at 12:00 a.m. (midnight) on the effective date of termination.
9.01 Reasons for Termination:
9.01.01
9.01.02
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)
Loss of eligibility. Subject to the conversion rights under Section 8.02:
a) Upon a loss of the Subscriber's or Dependent's eligibility as defined in Part IV,
including but not limited to the permanent relocation outside the Service Area, coverage
shall autornatically terminate on the last day of the month for wbich the monthly
premiurn was paid and during which the Subscriber and/or Dependent was eligible for
coverage.
b) Coverage for all Dependents shall automatically terminate on the last day of the month
for which the rnonthly premium was paid upon a loss of the Subscriber's eligibility, as
defmed in Part IV.
Failure to make premium payment. Upon failure of the Subscribing Group to make
payment of the monthly prernium provided in Part VII within ten days following the due
date specified herein, benefits hereunder shall terminate, for all Subscribers and any
Dependents for whom such payment has not been received, at 12:00 a.m. (midnight) on the
last day of the month for which the monthly premium was paid.
a) AvMed, regarding cancellation or non-renewal of this coverage, rnay retroactively
cancel the policy to the date for which the Subscribing Group's premiums have been
paid, when AvMed provides notice of cancellation or non-renewal to the Subscribing
Group, prior to 45 days after the date the premium was due. AvMed will include a
reason for the Contract termination in its written notification to the Subscribing Group.
The Subscribing Group will forward such notification to all Subscribers when AvMed
'I
I
I
15
")
')
9.01.03
9.01.04
10
9.01.05
)
9.01.06
A V -0100-2009
MP-53l9 (10/09)
has notified the Subscribing Group of the cancellation or non-renewal, and AvMed is
deemed to have complied with its notification requirements by providing said notice to
the Subscribing Group.
Termination of Group Contract by Snbscribing Gronp. Subscribing Group may
terminate this Group Contract on the anniversary date by giving written notice to AvMed 15
days prior to Contract anniversary date. In such event, benefits hereunder shall terminate for
all Mernbers at 12:00 a.m. (midnight) on the Contract expiration date.
Early termination of Group Cnntract by Snbscribing Grnnp. Subscribing Group may
terminate this Group Contract by giving at least 60 days written notice to AvMed. In such
event, benefits hereunder shall terminate for all Members at 12:00 a.m. (midnight) on the
date specified by the Group in their written notice to AvMed and for which premium was
paid.
Termination of Gronp Contract by AvMed. AvMed may non-renew or discontinue this
Gro.up Contract based on one or more of the conditions listed below. In such event, benefits
hereunder shall terminate for all Members at 12:00 a.m. (rnidnight) on the Contract
expiration date as described below.
a) Subscribing Group has failed to pay premiums or contributions in accordance with the
terms of this Contract or AvMed has not received timely premium payments. See Part
VII, Monthly Payments and Co-payments and Subsection 9.01.02. Termination of
coverage will be effective on the last day of the month for which payments were
received by AvMed.
b) Subscribing Group has performed an act or practice that constitutes fraud or made an
intentional misrepresentation of material fact under the terms of this Contract. This will
result in immediate termination of Subscribing Group.
c) Subscribing Group has failed to comply with a material provision of the Contract that
relates to rules for employer contributions or group participation. Termination will be
effective upon 45 days written notice frorn AvMed to Subscribing Group.
d) There is no longer any enrollee in connection with the Plan who lives, resides, or works
in the Service Area. Termination of coverage will be effective on the last day of the
month for which payrnents were received by AvMed.
e) AvMed ceases to offer coverage in the applicable rnarket. AvMed will provide written
notice to Subscribing Group at least 180 days prior to such termination.
Termination of cnverage for cause. AvMed may terminate any Member immediately upon
written notice for the following reasons which lead to a loss of eligibility of the Member:
a) Fraud, material misrepresentation, or omission in applying for membership, benefits, or
coverage under this Contract. However, relative to a misstatement in the Application,
after 2 years from the issue date, only fraudulent misstatements in the Application rnay
be used to void the policy or deny any claim for a loss occurred or disability starting
after the 2 year period;
b) Misuse of AvMed's identification card furnished to the Member;
c) Furnishing to AvMed incorrect or incomplete information for the purpose of ohtaining
membership, coverage, or benefits under this Contract; or
d) Behavior which is disruptive, unruly, abusive, or uncooperative to the extent that the
Member's continuing coverage under this Contract seriously impairs AvMed's ability to
16
1
administer this Contract or to arrange for the delivery of health care services to the
Member or other Members after AvMed has attempted to resolve the Member's
problem.
e) At the effective date of such termination, premium payments received by AvMed on
account of such termination shall be refunded on a pro rata basis, and AvMed shall have
no further liability or responsibility for the Member under this Contract.
9.02 Notification requirements:
)
Loss of eligihility of Subscriber. It is the responsibility of Subscribing Group to notifY
AvMed in writing within 31 days from the effective date of termination regarding any
Subscriber and/or Dependent who becomes ineligible to participate in the Plan. Failure of
the Subscribing Group to provide timely written notice as described above may lead to
retroactive termination of the Subscriber and/or Dependent. The effective date for such
retroactive termination will be the last day of the month for which the premiwn was paid and
during which the Subscriber and/or Dependent was eligible for coverage. See Section 7.06.
9.02.02 Loss of eligibility of Dependent. When a Dependent becomes ineligible for Dependent
coverage, the Subscriber is required to notifY AvMed in writing within 31 days of the
Dependent becoming ineligible.
9.02.01
'I
9.02.03 Contract termination. In the event this Contract is terminated, the Subscribing Group
agrees that it shall provide 45 days prior written notification of the date of such termination
to its employees who are Subscribers under this Contract.
. a) In no event will any retroactive termination of a Member be made beyond 60 days from
notification of the terminating event.
Certificates of Coverage. If your coverage under the Plan ends, you will autornatically receive a
Certificate of Group Health Plan Coverage. You rnay take this certificate to another health care plan to
receive credit for your coverage under the Plan. You will only need to do this if the other health care
plan has a pre-existing condition limit. You can request a Certificate of Group Health Plan Coverage
anytime during the 24-month period after the date your coverage under the Plan has ended.
9.04 Continuation Coverage under COBRA. Under certain provisions of COBRA, the Subscriber or his
Dependents may elect continued coverage under the Plan if coverage is lost due to a qualifYing event.
9.03
9.04.01
A V-OIOO-2009
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)
Eligibility. You or your covered Dependents will become eligible for continuation coverage
under COBRA after any of the following qualifYing events result in the loss of Plan
coverage:
a) Loss of benefits due to a reduction in your hours of employment;
b) Termination of your ernployment, including retirement but excluding termination for
gross misconduct;
c) Termination of employment following leave under the Family and Medical Leave Act
of 1993 (FMLA), in which case the qualifYing event will occur on the earlier of the date
you indicated you were not returning to work or the last day of the FMLA leave; or
d) You or a Dependent frrst become entitled to Medicare or covered under another group
health plan prior to your loss of coverage due to termination of employment or
reduction in hours.
e) In addition, your Dependents will become eligible for COBRA continuation coverage
after any of the following qualifYing events occur to cause a loss of Plan coverage,
17
I ) Your death;
2) Your divorce or legal separation;
3) You first become entitled to Medicare after your loss of coverage due to termination
of employment or reduction in hours; or
4) Your Dependent child no longer qualifies as a Dependent under the Plan.
t) A child who is born to (or placed for adoption) with a covered former employee during
the continuation coverage period has the same continuation coverage rights as a
Dependent child described above.
9.04.02 Notification. If a qualifying event other than divorce, legal separation, loss of Dependent
status or entitlement to Medicare occurs, the Plan Administrator will be notified of the
qualifying event by your employer and will send you an election form. To continue Plan
coverage, you must return the election form within 60 days from the later of the date you
receive the form, or the date your coverage ends due to a qualifying event.
a) If divorce, legal separation, loss of Dependent status or entitlernent to Medicare under
the Plan occurs, you or your covered Dependent must notify the Plan Administrator that
a qualifying event has occurred. This notification must be received by the Plan
Administrator within 60 days after the later of the date of such event, or the date you or
your eligible Dependent would lose coverage on account of such event. Failure to
promptly notify the Plan Administrator of these events will result in loss of the right to
continue coverage for you and your Dependents.
b) After receiving this notice, the Plan Administrator will send you an election form within
14 days. If you or your Dependents wish to elect continuation coverage, the election
form must be returned to the Plan Administrator within 60 days from the later of the
date you receive the form or the date your coverage ends due to the qualifying event.
Cost. If you elect to continue coverage, you must pay the entire cost of coverage (the
employer's contribution and the active employee portion of the contribution), plus a 2%
administrative fee for the duration of COBRA continuation coverage.
f)
)
()
)
9.04.03
9.04.04
A V -01 00-2009
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a) If you or your Dependent is Social Security disabled (Social Security disability status
rnust occur as defined by Title 11 or Title XVI of the Social Security Act), you may elect
to continue coverage for the disabled person only or for some or all of COBRA eligible
family members for up to 29 months if your employment is terminated or your hours
are reduced. You must pay 102% of the cost of coverage for the first 18 months of
COBRA continuation coverage and 150% of the cost of coverage for the 19th through
the 29th months of coverage. The Social Security disability date must occur within the
first 60 days of loss of coverage due to your termination of employment or reduction in
hours.
b) For COBRA coverage to remain in effect, payment must be received by the Plan
Administrator by the fmt day of the month for which the premium is due. (Your first
payrnent is due no later than 45 days after your election to continue coverage, and it
must cover the period of time back to the first day of your COBRA continuation
coverage).
Duration. COBRA Continuation Coverage can be extended for:
a) 18 months if coverage ended due to a reduction in your work hours or termination of
your employment and you or one of your covered Dependents is not Social Security
disabled within 60 days of the date you lose coverage due to termination of employment
18
)
or reduction in hours, the Medicare entitled person may elect up to 18 months of
COBRA. If you are that Medicare entitled person, your Dependents may elect COBRA
for the longer of 36 months frorn your prior Medicare entitlement date, or 18 months
from the date of your termination or reduction in hours; or
b) 36 months for your Dependents, if your Dependents lose eligibility for medical
coverage due to your death, your divorce or legal separation, your entitlement to
Medicare after your termination or reduction in hours, or your Dependent child ceasing
to qualifY as a Dependent under the Plan; or
c) 29 rnonths if you lose coverage due to a termination of employment or reduction in
hours and you or a Dependent is disabled, as defIDed by Title 11 or Title XVI of the
Social Security Act, within 60 days of the original qualifYing event. In this case, you
may continue coverage for an additional II months after the original 18-month period
either for the disabled person only or for one or all of your covered family members; or
d) To be eligible for extended coverage due to Social Security disability, you must notifY
the Plan Administrator of the disability before the end of the initial 18 months of
COBRA continuation coverage and within 60 days following the date you or a covered
Dependent is determined to be disabled by the Social Security Administration. If the
disabled individual should no longer be considered to be disabled by the Social Security
Administration, you must notifY the Plan Administrator within 30 days following the
end of the disability. Coverage that has exceeded the original l8-month continuation
period will end when the individual is no longer Social Security disabled.
e) If more than one qualifYing event occurs, no more than 36 months total of COBRA
continuation coverage will be available. The COBRA beneficiary must experience the
second qualifYing event during the first 18 rnonths of COBRA continuation, and must
provide notice to the Plan Administrator within the required time period. COBRA
continuation coverage will end sooner if the Plan terminates and the employer does not
provide replacement medical coverage, or if a person covered under COBRA:
I) First becomes covered under another group health plan after the loss of coverage
due to your termination or reduction in hours, unless the new group coverage is
limited due to a pre-existing condition exclusion; this Plan will be primary for the
pre-existing condition. and secondary for all other eligible health care expenses,
provided contributions for COBRA coverage continue to be paid. Coverage may
only continue for the rernainder of the original COBRA period;
2) Fails to make required contributions when due;
3) First becomes entitled to Medicare benefits after the initial COBRA qualifYing
event; or
)
-)
)
4) Is extending the 18-month coverage period because of disability and is no longer
disabled as defIDed by the Social Security Act.
9.05 Continuation Coverage during leaves of absence.
9.05.01
Family and Medical Leaves of Absence (FMLA). Under FMLA, you rnay be entitled to
up to a total of 12 weeks of unpaid, job-protected leave during each calendar year for the
following:
a) The birth of your child, to care for your newborn. child, or for placement of a child in
your horne for adoption or foster care;
b) To care for your spouse, child or parent with a serious health condition; or
19
A V -Gl 00-2009
MP-5319 (10/09)
c) For your own serious health condition.
d) If your FMLA leave is ... paid leave, your pay will be reduced by your before-tax
contributions as usual for the coverage level in effect on the date your FMLA leave
begins. If your FMLA leave is unpaid, you will be required to pay your contributions
directly to the employer until you return to active pay status.
e) If you notify your employer that you are terminating employment during your FMLA
leave, your coverage will end on the date of your notification. If you do not return to
work on your expected FMLA return date, and you do not notify your employer of your
intent either to terminate your employrnent or to extend the period of leave, your
coverage will end on the date you were expected to return.
f) You may not change your Plan elections during your FMLA leave unless an open
enrollment occurs or you are on a paid FMLA leave and you have a change in status
event or a special enrollment event under The Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
Military leaves of absence. If you are absent from work due to military service, you may
elect to continue coverage under the Plan (including coverage for enrolled Dependents) for
up to 18 months from the first day. of absence (or, if earlier, until the day after the date you
are required to apply for or return to active employment with your employer under the
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)). Your
contributions for continued coverage will be the same as for similarly situated active
participants in the Plan.
a) Whether or not you continue coverage during military service, you may reinstate
coverage under the Plan option you elected on your return to ernployment under
USERRA. The reinstatement will be without any waiting period otherwise required
under the Plan, except to the extent that you had not fully completed any required
waiting period prior to the start of the military service.
9.06 Conversion after Continuation Coverage. See Section 8.02.
f)
)
10
9.05.02
)
9.07 Extension of benefits. In the event this Contract is terminated for any reason, except nonpayment of
premium or as set forth in Subsection 9.07.03, such termination shall be without prejudice to any
continuous losses to a Member which commenced while this Contract was in force, but any extension of
benefits beyond the date of termination shall be predicated upon the continuous Total Disability as
defined in Section 3.48, of the Member and shall be limited to payment for the treatment of a specific
accident or illness incurred while coverage under this Contract was effective.
9.07.01
9.07.02
A V -01 00-2009
MP-5319 (10/09)
The extension of benefits covered under this Contract shall be limited to the occurrence of
the earliest of the following events:
a) The expiration of 12 months;
b) Such time as the Member is no longer totally disabled;
c) A succeeding carrier elects to provide replacement coverage without limitation as to the
disability condition; or
d) The maximum benefits payable under this Contract have been paid.
In the case of maternity coverage, when not covered by the succeeding carrier, a reasonable
extension of this Contract's benefits will be provided to cover maternity expenses for a
covered pregnancy that commenced while the policy was in effect. The extension shall be
for the period of that pregnancy only and shall not he based upon Total Disability.
20
")
9.07.03
Except as provided above, no Subscriber is entitled to an extension of benefits if the
termination by AvMed of this Contract is based upon one or rnore of the following reasons:
a) Fraud or intentional misrepresentation in applying for any benefits under this Contract;
h) Disenrollment for cause; or
c) The Subscriher has left the geographic Service Area of AvMed with the intent to
relocate or establish a new residence outside AvMed's Service Area.
)
X. SCHEDULE OF BASIC BENEFITS
AvMed is committed to arranging for comprehensive prepaid health care services rendered to its Subscribers
through AvMed's network of contracted independent physicians and Hospitals and other independent health care
providers, under reasonable standards of quality health care. The professional judgrnent of a physician licensed
under Chapter 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes,
concerning the proper course of treatment of a Subscriber shall not be subject to modification by AvMed or its
Board of Directors, Officers, or Administrators. However, this subsection is not intended to and shall not restrict
any Utilization Management Program established by AvMed.
Only services and benefits in conformity with Part III (DefInitions), Part X (Schedule of Basic BenefIts), Part XI
(Limitations of Basic Benefits), Part Xli (Exclusions frorn Basic Benefits) and the Schedule of Benefits, which
by reference is incorporated herein, are covered by AvMed. It is the Mernber's responsibility when seeking
benefits under this Contract to identifY himself as a Member of AvMed and to assure that the services received
by the Mernber are being rendered by Participating Providers. Any covered service for which the rnember is
seeking reirnbursernent, must be submitted to the plan within one year from the date of service to be considered.
Members must understand that services will not be covered if they are not, in AvMed' opinion, Medically
Necessary. Any and all decisions made by AvMed in administering the provisions of this Contract, including
without limitation, the provisions of Part X (Schedule of Basic Benefits), Part XI (Limitations of Basic
Benefits), and Part Xli (Exclusions frorn Basic Benefits), are rnade only to determine whether payment for any
benefits will be rnade by AvMed.
Any and all decisions that pertain to the medical need for, or desirability of the provision or non-provision of
Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services
or benefits, must be rnade solely by the Member and his physician, in accordance with the normal
patient/physician relationship for purposes of determining what is in the best interest of the Member.
AvMed does not have the right of control over the medical decisions made by the Member's physician or health
care providers. The ordering of a service by a physician, whether participating or non-participating, does not in
itself make such service Medically Necessary. Subscrihing Group and Mernber acknowledge that it is possible
that a Member and his physician may determine that such services or supplies are appropriate even though such
services or supplies are not covered and will not be arranged or paid for by AvMed.
Members should remember that services that are provided or received without advance authorization from
AvMed, or when the service is beyond the scope of practice authorized for that provider under State law, are not
covered unless such services otherwise have been expressly authorized under the terms of this Contract or when
required to treat an Emergency Medical Condition. Except for Emergency Medical Services and Care, all
services rnust be received from Participating Providers. Any Member requiring medical, Hospital, or ambulance
services for ernergencies (as described in Sections 3.16 and 3.17), either while temporarily outside the Service
Area, or within the Service Area but before they can reach a Participating Provider, may receive the emergency
benefits as specified in Section 10.11.
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If a Member does not follow the access rules, he risks having the services and supplies received not covered
under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum
Allowable Payment and the Member will be responsible for reimbursing AvMed any Maximum Allowable
Payment rnade for the services and supplies received.
The following services require prior authorization from AvMed:
. Inpatient admissions
. All Home Health Care Services
. Complex diagnostic procedures
. Surgical procedures or services performed in an outpatient Hospital, Hospital-affiliated ambulatory
surgery center, or free-standing ambulatory surgery center
. All medications administered in an outpatient Hospital or infusion therapy setting
. Select medications administered in a physician's office
. Care rendered by Non-participating Providers (except for Emergency Medical Services and Care)
. Transplant services
. Dialysis services
Forrnore information about which services require prior authorization, contact AvMed at 1-800-882-8633.
\Vithin the Service Are~ Members are entitled to receive the covered services and benefits only as herein
specified, appropriately prescribed or directed by Participating Physicians. The covered services and benefits
listed in the section entitled Schedule of Basic Benefits are available only from Participating Providers within
the Service Area and, except for Emergency Medical Services and Care as provided in Section 10.11, AvMed
shall have no liability or obligation whatsoever on account of services or benefits sought or received by any
Member from any Non-participating Provider, or other person. institution or organization, unless prior
arrangements have been made for the Mernber and confirmed by written referral or authorization from AvMed.
The names and addresses of Participating Providers and Hospitals are set forth in a separate booklet which, by
reference, is made a Part hereof. The list of Participating Providers, which may change from time to time, will
be provided to all Subscribing Groups. The list of Participating Providers may also be accessed from the AvMed
Website at www.avmed.org. Notwithstanding the printed booklet, the names and addresses of Participating
Providers on file with AvMed at any given time shall constitute the official and controlling list of Participating
Providers. Pursuant to Florida Statute, there is a link available on the AvMed Website to view the performance
outcome and financial data that is published by the Florida Agency for Health Care Administration.
Each Member shall select one Primary Care Physician upon enrollment. If you do not select a Primary Care
Physician upon enrollment, AvMed will assign one for you. You must notify and receive approval from AvMed
prior to changing your Primary Care Physician. Such change will become effective on the first day of the month
after you notifY AvMed. You cannot change your Primary Care Physician selection more than once per month.
Health Professionals may from time to time cease their affiliation with AvMed. In such cases, you will be
required to receive services from another participating Health Professional.
MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR CO-PAYMENTS WmCH MUST BE
PAID TO HEALTH CARE PROVIDERS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE
RENDERED, AS SET FORTH IN THE SCHEDULE OF BENEFITS.
10.01 Ambulance services as follows:
10.01.01 Local professional air/ground ambulance transport for emergency services to the nearest
emergency department appropriately staffed and equipped to treat a medical condition;
10.01.02 Ground transportation to an alternative level of care when associated with an approved
Hospital confinement; and
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10.01.03 Ground transportation to a Member's home will be covered when associated with an
approved hospitalization or other confmement and the Member's condition requires the skill
of medically trained personnel. Transportation is not covered when the skill of medically
trained personnel is not required and the Member can be safely transferred (or transported)
hy other means.
10.01.04 Air ambulance transportation is covered only when the point of pick-up is inaccessible by
land or when distance or other obstacles are involved in transporting the Member to the
nearest emergency department equipped to adequately treat the medical condition. See Part
XU for Exclusions.
10.02 Cardiac rehabilitation. Cardiac rehabilitation is covered for the following conditions: acute myocardial
infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft
(CABG), repair or replacement of heart valves or heart transplant. Coverage is limited to a maximum of
18 visits per calendar year. See Schedule of Benefits for detailed information regarding Co-payments
and Limitations.
10.03 Coverage for cleft lip and cleft palate for Members under 18 years of age. The coverage provided
hy this Section is subject to the terms and conditions applicable to other benefits.
10.04 Dermatological services. AvMed will cover office visits to a participating dermatologist for Medically
Necessary covered services subject to Section 3.30. No prior referral is required for these services.
10.05 Diabetes treatment includes all Medically Necessary equipment, supplies, and services to treat
diabetes. This includes outpatient self-management training and educational services, if the Member's
Primary Care Physician or the physician to whom the Member has been referred who specializes in
diabetes treatment, certifies the equipment, supplies or services are Medically Necessary. Insulin pumps
are covered under Suhsection 10.10.05. Diabetes outpatient self-rnanagement training and educational
services must be provided under the direct supervision of a certified diabetes educator or a board
certified endocrinologist under contract with AvMed. In accordance with Florida Statutes, coverage of
insulin purnps for the treatment of diabetes will not apply toward or be subject to the annual DME
maximum limitation. See also Section 10.06.
10.06 Diabetic supplies. Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing
Group's supplemental prescription medication benefits. In the event a Subscribing Group does not
purchase supplemental prescription medication benefits, insulin, insulin syringes, lancets, and test strips
are covered subject to a $25 Co-payment per item for a 30-day supply. See also 10.05.
10.07 Diagnosis and treatment of Autism Spectrum Disorder through speech therapy, occupational therapy,
physical therapy, and Applied Behavior Analysis services for an individual under 18 years of age or an
individual 18 years of age or older who is in high school who has been diagnosed as having a
developrnental disability at 8 years of age or younger.
10.07.01 Coverage shall be lirnited to services that are prescribed by the treating physician in
accordance with a treatment plan. The treatment plan required shall include, but is not
limited to, a diagnosis, the proposed treatment by type, the frequency and duration of
treatment, the anticipated outcomes stated as goals, the frequency with which the treatment
plan will be updated, and the signature of the treating physician. Coverage for these services
shall be limited to $36,000 annually and may not exceed $200,000 in total benefits.
10.07.02 Coverage is subject to applicable Co-payments and coverage limitations as set forth in the
Schedule of Benefits.
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10.08 Diagnostic imaging and laboratory. All prescribed diagnostic imaging and laboratory tests and
services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and other
laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and
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ordered by a Participating Physician as part of the diagnosis and/or treatment of a covered illness or
injury or as preventive health care services.
Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADHD).
Coverage is subject to applicable Co-payments and coverage limitations as outlined on the Schedule of
Benefits. Covered services do not include those that are primarily educational or training in nature.
Durable Medical Equipment (DME). This Contract provides benefits, when Medically Necessary, for
the purchase or rental of such DME that:
10.10
10.10.01
10.10.02
10.10.03
10.10.04
Can withstand repeated use (I.e. could normally be rented and used by successive patients);
Is primarily and customarily used to serve a medical purpose;
Generally is not useful to a person in the absence of illness or injury; and
Is appropriate for use in a patient's home.
10.10.05 Some examples of DME are: hospital beds, crutches, canes, walkers, wheelchairs, oxygen,
respiratory equipment, apnea monitors and insulin pumps. It does not include hearing aids
or corrective lenses, or the professional fee for fitting same. It also does not include medical
supplies and devices, such as a corset, which do not require prescriptions. AvMed will pay
for rental of equiprnent up to the purchase price. Repair and/or replacements are not
covered.
10.10.06 Oxygen is covered when Medically Necessary pursuant to AvMed's coverage guidelines,
which are available free of charge upon request. The type of oxygen delivery system
covered (stationary, portable, ambulatory) is based on the Member's activity status. Initial
coverage is contingent upon arterial blood gas results. Reassessment of oxygen needs
through pulse oximetry at rest and after exercise is required and must be performed by an
independent respiratory provider at 3 months after the initiation of therapy and then yearly in
order to re-qualify coverage of oxygen therapy.
10.10.07 The determination of whether a covered item will be paid under the DME, orthotics or
prosthetics benefits will be based upon its classification as defIDed by the Centers for
Medicare and Medicaid Services. See Schedule of Benefits for any Co-payments or
Limitations. See Part XII for Exclusions.
10.11 Emergency services. AvMed will cover all necessary physician and Hospital Services for Emergency
Medical Services and Care. See Part 111, Sections 3.16 and 3.17. In the event Hospital inpatient services
are provided following Emergency Medical Services and Care, AvMed should be notified by the
Hospital, Member or designee, within 24 hours of the inpatient admission if reasonably possible.
AvMed may elect to transfer the Member to a participating provider as soon as it is medically
appropriate to do so. If the Member chooses to stay in the Non-participating facility after the date
AvMed decides a transfer is medically appropriate, out-of-network benefits may be available if the
continued stay is determined to be a covered health service. In addition, any Member requests for
reimbursernent (of payment made by the Member for services rendered) must be filed within 90 days
after the emergency or as soon as reasonably possible but not later than one year unless the Claimant
was legally incapacitated.
10.12 General anesthesia and hospitalization services to a Member who is under 8 years of age and is
determined by a licensed dentist and the Member's physician to require necessary dental treatment in a
Hospital or ambulatory surgical center due to a significantly complex dental condition or a
developmental disability in which patient management in the dental office has proved to be ineffective;
or iftbe Member has one or more medical conditions that would create significant or undue medical risk
for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in
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a Hospital or amhulatory surgical center. Pre-authorization by AvMed is required. There is no coverage
for diagnosis or treatment of dental disease.
10.13 Hospital care: inpatient. All Hospital inpatient services received at Participating Hospitals for non-
mental illness or injury are provided when prescribed by Participating Physicians and pre-authorized by
AvMed. Inpatient services include semi-private room and board, birthing rooms, newborn nursery care,
nursing care, meals and special diets when Medically Necessary, use of operating rooms and related
facilities, the intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests,
medications, biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory
therapy, and administration of blood or blood plasma. See Section 10.11 with regard to inpatient
admission following Emergency Medical Services and Care.
10 .14 Hospice services. Services are available from a participating Hospice organization for a Mernber
whose Participating Physician has determined the Member's illness will result in a remaining life span
of 6 months or less.
10.15 Major organ transplants at a facility deemed appropriate and authorized by AvMed, as well as
associated immunosuppressant medications are covered except those deemed experimental. See Section
12.14.
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10.16 Mammograms are covered in accordance with Florida Statutes. One baseline mammogram is covered
for female Members between the ages of 35 and 39. A mammogram is available every 2 years for
female Mernbers between the ages of 40 and 49 and a manunogram is available every year for female
Members aged 50 and older.
10.16.01 In addition, one or more mamrnograrns a year are available when based upon a physician's
recommendation for any woman who is at risk for breast cancer because of a personal or
family history of breast cancer, because of having a history of biopsy-proven benign breast
disease, because of having a mother, sister, or daughter who bas had breast cancer, or
because a woman has not given birth before the age of30.
10.17 Mastectomy surgery when performed for breast cancer. Coverage for post-mastectomy reconstructive
surgery shall include:
)
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction on the other breast to produce a symmetrical appearance; and
Prostheses and physical complications during all stages of mastectomy including
Iymphedemas.
The length of stay will not be less than that determined by the Attending Physician to be
Medically Necessary in accordance with prevailing rnedical standards and after consultation
with the covered patient. The Attending Physician, after consultation with the covered
patient, may choose that the outpatient care be provided at the most medically appropriate
setting, which may include the hospital, treating physician's office, outpatient center, or
home of the covered patient.
10.17.05 Coverage is subject to any applicable Co-payrnents and will require pre-authorization of
services as applicable to other surgical procedures or hospitalizations under the Plan.
10.18 Newborn care. All services applicable for children under this Contract are covered for an enrolled
newborn child of the Subscriber or the enrolled newborn child ofa covered Dependent of the Subscriber
or the newborn adopted child of the Subscriber (as described in Subsection 4.02.02 (i)), from the
moment of birth, including the Medically Necessary care or treatment of medically diagnosed
congenital defects, birth abnormalities or prematurity, and transportation costs to the nearest facility
10.17.01
10.17.02
10.17.03
10.17.04
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) appropriately staffed and equipped to treat the newborn's condition, when such transportation is
Medically Necessary. Circumcisions are provided for up to one year from date of birth.
10.19 Non-participating Provider services. When, in the professional judgment of AvMed's Medical
Director, a Member needs covered Medical Services or Hospital Services which require skills or
facilities not available from Participating Providers and it is in the best interest of the Mernber to obtain
the needed care from a Non-participating Provider, upon authorization by the Medical Director.
Payment may not exceed the Maximum Allowable Payment for such covered services rendered by a
Non-participating Provider. The amounts requested for payment for non-participating Hospital Services
will be reimbursed in accordance with the covered benefits the Member would be entitled to receive in a
Participating Hospital.
10.20 Obstetrical and gynecological care. An annual gynecological examination and Medically Necessary
follow-up care detected at that visit are available without the need for a prior referral from the Primary
Care Physician. Obstetrical care benefits as specified herein are covered and include Hospital care,
anesthesia, diagnostic imaging, and laboratory services for conditions related to pregnancy unless such
pregnancy is the result of a preplanned adoption arrangement, more commonly known as surrogacy.
The length of maternity stay in a Hospital will be that determined to be Medically Necessary in
compliance with Florida law and in accordance with the Newborns' and Mothers' Health Protection Act,
as follows:
10.20.01 Hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours
following a cesarean section;
10.20.02 The Attending Physician does not need to obtain authorization from AvMed to prescribe a
Hospital stay of this length;
10.20.03 AvMed will cover an extended stay, if Medically Necessary; however, your physician or
your Hospital must precertifY the extended stay.
10.20.04 Shorter Hospital stays are permitted if the attending health care provider, in consultation
with the mother, detennines that to be best course of action. Coverage for maternity care is
subject to applicable Co-payments and all other Plan limits and requirements.
10.21 Orthotic appliances. Coverage for orthotic appliances is limited to custom-made leg, arm, back and
neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when
necessary to cany out normal activities of daily living, excluding sports activities. Coverage includes
the initial purchase, fitting or adjustrnent. Replacernents are covered only when Medically Necessary
due to a change in bodily configuration. All other orthotic appliances are not covered. The determination
of whether a covered itern will be paid under the DME, orthotics or prosthetics benefits will he based
upon its classification as defined by the Centers for Medicare and Medicaid Services. See Schedule of
Benefits for any Co-payments or Limitations. See Part XI for Exclusions.
)
10.22 Osteoporosis diagnosis and treatment when Medically Necessary for high-risk individuals, e.g.
estrogen-deficient individuals, individuals with vertebral abnormalities, individuals on long-term
glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism, and individuals with a
family history of osteoporosis.
10.23 Other health care facility(ies). All routine services of Other Health Care Facilities (see Section 3.35),
including physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered for a
maximum of 20 days per calendar year when a Member is admitted to such a facility, following
discharge from a Hospital, for a condition that cannot be adequately treated with Skilled Home Health
Care Services or on an ambulatory basis.
10.24 Outpatient therapeutic services. Covered health services for therapeutic treatments received on an
outpatient basis in your home, physician's office, Other Health Care Facility or Hospital, including
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intravenous chemotherapy or other intravenous infusion therapy and Injectable Medications. Self-
Administered Injectable Medications are only a covered benefit when included in the supplemental
prescription medication benefits. See Section 12.29.
10.25 Physician care: inpatient. All Medical Services rendered by Participating Physicians and other Health
Professionals when requested or directed by the Attending Physician, including surgical procedures,
anesthesia, consultation and treatrnent by Specialty Health Care Physicians, laboratory and diagnostic
imaging services, and physical therapy (see Section 10.28) are covered while the Member is admitted to
a Participating Hospital as a registered bed patient. When available and requested by the Mernber,
AvMed covers the services of a certified nurse anesthetist licensed under Chapter 464, Florida Statutes.
10:26 Physician care: outpatient
10.26.01 Diagnosis and treatment. All Medical Services rendered by Participating Physicians and
other Health Professionals, as requested or directed by the Primary Care Physician, are
covered when Medically Necessary and when provided at Medical Offices, including
surgical procedures, routine hearing examinations and vision examinations for glasses for
children under age 18 (such examinations may be provided by optometrists licensed
pursuant to Chapter 463, Florida Statutes or by ophthalrnologists licensed pursuant to
Chapter 458 or 459, Florida Statutes) and consultation and treatment by Specialty Health
Care Physicians. Also included are non-reusable materials and surgical supplies. These
services and materials are subject to the Lirnitations outlined in Part XI (Limitations of Basic
Benefits). See Part Xli for Exclusions.
10.26.02 Preventive and health maintenance services. The services of the Member's Primary Care
Physician for illness prevention and health maintenance, including child health supervision
services and immunizations provided in accordance with prevailing medical standards
consistent with the Recommendations for Preventive Pediatric Health Care of the American
Academy of Pediatrics and/or the Advisory Committee on Immunization Practices; periodic
health assessment and physical examinations are also covered. These services are subject to
Limitations as outlined in Part XI (Limitations of Basic Benefits). See Part Xli for
Exclusions.
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10.27 Physical, occupational or speech therapy. Short-term physical, occupational or speech therapy
provided in an outpatient or home care setting is covered for acute conditions, including exacerbation of
previously treated conditions, for which therapy applied for a consecutive 2 month period can be
expected to result in significant improvement. Coverage of outpatient short-term and rehabilitative
services is limited as outlined on the Schedule of Benefits. Long-term physical therapy, occupational
therapy, speech therapy, rehabilitation, or other treatment is not covered.
10.28 Prescription medication benefits. Allergy serums and chemotherapy for cancer patients are covered.
Coverage for insulin and other diabetic supplies is described in Section 10.06 above. Other retail
prescription medications are a covered benefit only when the Subscribing Group Contract includes
supplemental prescription medication benefits; coverage is subject to the Co-payment/Co-insurance
provisions outlined therein.
10.29 Prosthetic devices. This Contract provides benefits, when Medically Necessary, for prosthetic devices
designed to restore bodily function or replace a physical portion of the body. Coverage for prosthetic
devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. Coverage
includes the initial purchase, fitting, or adjustment. Replacernent is covered only when Medically
Necessary due to a change in bodily configuration. The initial prosthetic device following a covered
mastectorny is also covered. Replacement of intraocular lenses is covered only if there is a change in
prescription that cannot be accommodated by eyeglasses. All other prosthetic devices are not covered
including prosthetic devices for Deluxe, Myo-electric and electronic prosthetic devices. The
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determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits
will be based upon its classification as defIDed by the Centers for Medicare and Medicaid Services. See
Schedule of Benefits for any Co-payments or Limitations. See Part XII for Exclusions.
10.30 Second medical opinions. The Member is entitled to a second medical opinion when he disputes the
appropriateness or necessity of a surgical procedure or is subject to a serious injury or illness.
10.30.01 The Member may obtain a second medical opinion from any physician who is within
AvMed's Service Area If you chose a Participating Physician, there is no prior authorization
requirement. You pay only the applicable Co-payment or Deductible and Co-insurance. If
you choose a non-participating physician, the service is subject to prior authorization
requirements. You are also responsible for 40% of the amount of the Maximum Allowable
Payment associated with the consultation.
10.30.02 Any tests that may be required to render the second medical opinion must be arranged by
AvMed and performed by Participating Providers. Once a second medical opinion has been
rendered, AvMed shall review and determine AvMed's obligations under the Contract and
that judgment is controlling. Any treatment the Member obtains that is not authorized by
AvMed shal1 he at the Member's expense.
10.30.03 AvMed may limit second medical opinions in connection with a particular diagnosis or
treatment to 3 per calendar year, if AvMed deems additional opinions to be an unreasonable
over-utilization by the Member.
10.31 Skilled Home Health Care Services. Home Health Care Services (as defmed in Section 3.22) are
covered as outlined on the Schedule of Benefits when ordered by and under the direction of the
Member's Attending Physician. Physical, occupational or speech therapy services provided in the home
are limited as noted in Section 10.28. Home Health Care Services that do not include a medical,
diagnostic, therapeutic or rehabilitative component, or that do not require the skill of a registered nurse,
licensed practical (vocational) nurse or other healthcare personnel are not covered. Homemaker or other,
Custodial Care services are not covered.
10.32 Spinal manipulations will be covered only when Medical1y Necessary and prescribed by a
Participating Physician or by self-referral to a Participating Physician.
10.33 Supplies. Ostorny, urostomy and wound care supplies, and urinary catheter bags are covered when
Medical1y Necessary. Provision of ostomy and urostomy supplies are lirnited to a one-month supply
every 30 days. Coverage is limited to $2,500 per Contract Year, subject to applicable Co-payments and
Co-Insurance. Items which are not medical supplies or which could be used by the Member or a farnily
member for purposes other than ostomy care are not covered.
10.34 Urgent Care services. Al1 necessary and covered services received in Urgent Care or Immediate Care
Centers or rendered in your Primary Care Physician's office after-hours for conditions as described in
Section 3.50 will be covered by AvMed. See Schedule of Benefits for details. In addition, any Mernber
requests for reimbursement (of payment rnade by the Member for services rendered) must be filed
within 90 days after the emergency or as soon as reasonably possible but not later than one year unless
the Claimant was legal1y incapacitated.
10.35 Ventilator dependent care. With prior authorization by AvMed, ventilator dependent care (see Section
3.53) is covered up to a total of 100 days lifetime maximum benefit.
XI. LIMITATIONS OF BASIC BENEFITS
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The rights of Members and obligations of Participating Providers hereunder are subject to the following
Limitations:
11.01 Cardiac rehabilitation. Coverage is limited to a maximum of 18 visits per calendar year.
11.02 Diagnosis and treatment of Antism Spectrnm Disorder. Coverage for the diagnosis and treatment of
Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total
benefits.
11.03 HOl)le Health Care Services (Skilled Home Healtb Care) visits are limited to a period of 2 hours or
less.
11.04 Hyperbaric oxygen treatments are limited to 40 treatments per condition as appropriate pursuant to
the Centers for Medicare and Medicaid Services (CMS) guidelines, subject to applicable Co-payments
as listed for physical, speech and occupational therapies.
11.05 Licensed dietitians/nntritionists. Visits to licensed dietitians/nutritionists for treatment of diabetes,
renal disease or obesity control shall be limited to 3 outpatient visits per calendar year and each visit
requires a Co-payment. See Schedule of Benefits and also Section 12.17.
11.06 Ortbotic appliances. Coverage for orthotic appliances is limited to custorn-made leg, arm, back and
neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when
necessary to carry out normal activities of daily living, excluding sports activities.
11.07 Otber Health Care Facility(ies). All routine inpatient services of other health care facilities (see
Section 3.35), including physician visits, physiotherapy, diagnostic imaging and lahoratory work, are
covered for a maxirnum of 20 days per calendar year when a Member is admitted to such a facility,
following discharge from a Hospital, for a condition that cannot be adequately treated with Horne
Health Care Services or on an ambulatory basis.
11.08 Physical, occupational or speech therapy. Physical, occupational or speech therapies shall be limited
as explained in Sections 10.28 and 10.3.
11.09 Prosthetic devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular
prostheses and cochlear implants.
11.10 Second medical opinions. AvMed rnay lirnit second medical opinions in connection with a particular
diagnosis or treatment to 3 per calendar year, if AvMed deems additional opinions to be an unreasonable
over-utilization by the Mernber.
11.11 Speech therapy. Coverage is limited to 24 visits per calendar year including evaluations.
11.12 Snbstance ahnse - Hospital Lirnitation. Inpatient services for alcohol and drug abuse"shall be provided
but only for acute detoxification and the treatment of other medical sequelae of such abuse. Inpatient
alcohol or drug rehabilitation services are not covered.
11.13 Snpplies. Provision of ostomy and urostomy supplies are limited to a one-rnonth supply every 30 days.
Coverage is limited to $2,500 per Contract Year, subject to applicable Co-payments and Co-Insurance.
11.14 Ventilator dependent care. The total benefit for ventilator dependent care is limited to 100 calendar
days lifetime maximum.
11.15 Transplant services. Transportation benefits for transplant services are administered through Opium
Health, an AvMed third party partner. Benefits are limited to $200 per day up to $10,000 lifetime
maximum for a companion to accompany the Member (or 2 companions when the patient is a minor)
and the rnember has to travel greater than a 50 mile radius to receive the transplant. This is a henefit
available only when the transplant is authorized at one of AvMed's transplant contracted facilities
nationwide.
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XU. EXCLUSIONS FROM BASIC BENEFITS
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Medical Services and benefits for the following classifications and conditions are Dot covered and are excluded
from the Schedule of Basic Benefits provided under this Contract:\
12.01 Aids or devices that assist with nonverbal communications, including but not limited to
communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal
Digital Assistants (PDAs) Braille typewriters, visual alert systems for the deaf and memory books.
12.02 Autopsy or postmortem examinatinns and associated services, including the autopsy.
12.03 Breast reduction or augmentatinn. Surgery for the reduction or augmentation of the size of the breasts
except as required for the comprehensive treatment of breast cancer.
12.04 Complementary or alternative medicine including, but not limited to, self-care or self-help training;
horneopathic medicine and counseling; Ayurvedic medicine such as lifestyle modifications and
purification therapies; traditional Oriental medicine including acupuncture; naturopathic medicine;
environmental medicine including the field of clinical ecology; chelation therapy; thermography; mind-
body interactions such as meditation, imagery, yoga, dance, and art therapy; biofeedback; hypnotherapy;
prayer and mental healing; manual healing methods such as the Alexander teclmique, aromatherapy,
massage therapy including but not limited to: Ayurvedic rnassage, craniosacral balancing, Feldenkrais
method, Hellerwork, reflexology, rolfmg, shiatsu, traditional Chinese massage, Trager therapy, trigger-
point myotherapy, and polarity therapy. Reichian therapy, biofield therapeutics; Reiki, SHEN therapy,
and therapeutic touch; bioelectromagnetic applications in medicine; herbal therapies; sleep therapy, sex
therapy, behavioral training, cognitive therapy, and vocational rehabilitation.
12.05 Complications of any non-covered service, including the evaluation or treatment of any condition that
arises as a complication of ~ non-covered service.
12.06 Cosmetic, surgical or non-surgical procedures which are undertaken primarily to improve or
otherwise modify the Member's external appearance are excluded, except for reconstructive surgery to
correct and repair a functional disorder as a result of a disease, injury, or congenital defect or initial
implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast. Also
excluded are surgical excision or reformation of any sagging skin of any part of the body, including, but
not limited to: the eyelids, face, neck, abdomen, arms, legs, or buttocks; any services performed in
connection with the enlargement, reduction, implantation or change in appearance of a portion of the
body, including, but not limited to: the face, lips, jaw, chin, nose, ears, breasts, or genitals (including
circumcision, except newborns for up to one year from date of birth; see also Section 10.18); hair
transplantation, chemical face peels or abrasion of the skin, electrolysis depilation, removal of tattooing;
or any other surgical or non-surgical procedures which are primarily for cosmetic purposes or to create
body symmetry. Additionally, all medical cornplications as a result of cosmetic, surgical or non-surgical
procedures are excluded.
12.07 Cosmetics, dietary supplements, nutritional formnlae, health or beauty aids.
12.08 Custodial Care (as defmed in Part III, Section 3.13).
12.09 Dental Care, as defined in Section 3.11, for any condition except:
12.09.01 When such services are for the treatment of trauma related fractures of the jaw or facial
bones or for the treatment of tumors;
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12.09.02 Reconstructive jaw surgery for the treatment of deformities that are present and apparent at
birth; or
12.09.03 Full mouth extraction when required before radiation therapy.
12.10 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities,
behavioral problems and developmental delays. Expenses for remedial or special education, counseling,
or therapy including evaluation and treatment of the above-listed conditions or behavioral training
whether or not associated with manifest mental disorders or other disturbances.
12.11 Durable Medical Equipment (DME). Non-covered include (but are not limited to) the following:
12.11.01 Bed Related Items: bed trays, over the bed tables, hed wedges, pillows, custom bedroom
equipment, mattresses, including non-power mattresses, custom mattresses and posturepedic
mattresses;
')
12.1 J .02 Bath Related Items: bath lifts, non-portable whirlpools, bathtub rails, toilet rails, raised toilet
seats, bath benches, bath stools, hand held showers, paraffm baths, bath mats, and spas;
12.11.03 Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about
chairs, geriatric chairs, hip chairs, seat lifts (rnechanical or motorized), patient lifts
(mechanical or motorized - manual hydraulic lifts are covered if patient is 2-person transfer),
and auto tilt chairs;
12.11.04 Fixtures to Real Property: ceiling lifts and wheelchair ramps;
12.11.05 CarNan Modifications;
12.11.06 Air Quality Items: roorn humidifiers, vaporizers, air purifiers and electrostatic machines;
12.11.07 Blood/Injection Related Items: blood pressure cuffs, centrifuges, nova pens and needle less
injectors; and
12.11.08 Other Equiprnent: heat lamps, heating pads, cryounits, cryotherapy machines, electronic-
controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
hoard, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult), stair
gliders, elevators, saunas, any exercise equipment and diathermy machines.
12.12 Emergency room services for non-emergency purposes. See Sections 3.16 and 3.17.
12.13 Exercise programs, gyrn memberships, or exercise equiprnent of any kind, including, but not limited
to: exercise bicycles, treadmills, stairmasters, rowing machines, free weights or resistance equipment.
Also excluded are massage devices, portable whirlpool pumps, hot tubs, jacuzzis, sauna baths,
swimming pools and similar equipment.
12.14 Experimental and/or investigational procedures, except for bone marrow transplants, as approved per
Florida Administrative Code, Section 59B-12.001. For the purposes of this Contract, a medication,
treatment, device, surgery or procedure may be determined to be experimental and/or investigational if
any of the following applies:
12.14.01 The FDA has not granted the approval for general use;
12.14.02 There are insufficient outcomes data available frorn controlled clinical trials published in
peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury
involved;
12.14.03 There is no consensus among practicing physicians that the medication, treatment, therapy,rprocedure or device is safe or effective for the treatment in question or such medication,
treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or
.j
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device utilized by practicing physicians in treating other patients with the same or a similar
condition; or
Such rnedication, treatment, procedure or device is the subject of an ongoing Phase I or
Phase 11 clinical investigation, or experimental or research arm of a Phase ill clinical
investigation, or under study to determine: maximum tolerated dosages, toxicity, safety,
efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the
condition in question:
12.15 Eye care including:
12.15.01 Eye examinations for Members 18 years of age or older for the purpose of determining the
need for sight correction (such as eye glasses or contact lenses);
12.14.04
lil
Training or orthoptics, including eye exercises; or
Radial keratotomy, refractory keratoplasty, Lasik surgery or any other corneal surgical
procedure to correct refractive error.
12.16 Foot supports are not covered. These include orthopedic or specialty shoes, shoe build-ups, shoe
orthotics, shoe braces, and shoe supports. Also excluded is routine foot care, including trimming of
corns, calluses, and nails.
12.15.02
12.15.03
12.17 Gastric stapling, gastric bypass, gastric banding, gastric bubbles, and other procedures for the
treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests. Ongoing
visits other than establishing a program of obesity control.
12.18 Gender reassignment surgery as well as any service, supply, or medical care associated with gender
reassignment or gender identity disorders.
12.19 Home monitoring devices and measuring devices (other than apnea monitors), and any other
equipment or devices for use outside the Hospital.
12.20 Hospital Services that are associated with excluded surgery or Dental Care.
12.21 Hearing examinations for Members 18 years of age or older for the purpose of determining the need
for hearing correction.
12.22 Infertility diagnosis, trcatment, and supplics, including infertility testing, treatment of infertility,
diagnostic procedures and artificial insemination, to determine or correct the cause or reason for
infertility or inability to achieve conception. This includes artificial insemination, in-vitro fertilization,
ovwn or embryo placement or transfer, gamete intra-fallopian tube transfer, or cryogenic or other
preservation techniques used in such or sirnilar procedures. Also excluded are obstetrical benefits when
such pregnancy is the subject of a preplanned adoption arrangement, or surrogacy, as defined under
Cbapter 63, Florida Statutes. Medications for the treatment of infertility are not covered.
12.23 Immunizations and medications for the purpose of foreign travel or employment.
12.24 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions caused
by congenital or developmental deformity, disease, or injury.
12.25 Medical care or surgery not authorized by a Participating provider, except for Ernergency Medical
Services and Care, or not within the benefits covered by AvMed.
12.26 Medical supplies including, but not limited to: pre-fabricated splints, Thromboemboletic/Support hose
and all other bandages, except as provided in Sections 10.22 and 10.37.
12.27 Non-participating Providers. Any treatment or service frorn a Non-participating Provider, except in
the case of an ernergency or when specifically pre-authorized by AvMed (see Sections 3.16 and 3.17),
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including hospital care frorn a non-participating Attending Physician or a non-participating Hospital, if
elected by a member. In such circumstances, coverage is excluded for the entire episode of care, except
when the admission was due to an emergency or with the prior written authorization of AvMed.
12.28 Organ donor treatment and services. the Medical Services and Hospital Services for a donor or
prospective donor who is an AvMed Member when the recipient of an organ transplant is not an AvMed
Member. Coverage is provided for costs associated with the bone rnarrow donor-patients to the same
extent as the insured recipient. The reasonable costs of searching for the bone marrow donor is limited
to family members and the National Bone Marrow Donor Program. Post-transplant donor
complications will not he covered.
12.29 Over-the-counter medications, and prescription medications not otherwise covered including all
contraceptives (medications and devices), hypodennic needles and syringes and Self-Administered
Injectable Medications except insulin and insulin syringes for the treatment of diabetes as outlined in
Section 10.06.
12.30 Personal comfort items not Medically Necessary for proper medical care as Part of the therapeutic plan
to treat or arrest the progression of an illness or injury. This Exclusion includes, but is not limited to:
wigs (including partial hair pieces, weaves, and toupees), personal care kits, guest meals and
accommodations, maid services, televisions/radios, telephone charges, photographs, complimentary
meals, birth announcements, take horne supplies, travel expenses (other than Medically Necessary
ambulance services that are provided for in Section 10.01), air conditioners, humidifiers, dehumidifiers,
and air purifiers or filters.
12.31 Physical examinations or tests, such as premarital blood tests or tests for continuing employrnent,
education, licensing, or insurance or that are otheIVIise required by a third party.
12.32 Private dnty nursing services.
12.33 Rehahilitation programs. Alcohol or substance abuse rehabilitation, vocational rehabilitation,
pulmonary rehabilitation, long term rehabilitation, or any other rehabilitation program.
12.34 Removal of benign skin lesions and warts, moles, skin tags, lipomas, keloids, and scars, is not covered,
even with a recommendation or prescription by a physician.
12.35 Reversal of sterilization procedures.
12.36 Sexual dysfunction. All rnedications, devices, and other forms of treatment related to a diagnosis of
sexual dysfunction, regardless of etiology.
12.37 Smoking cessation. Any service or supply to eliminate or reduce dependency on or addiction to
tobacco, including but not limited to: nicotine withdrawal programs, facilities, and supplies (e.g.
transderrnal patches, Nicorette gum).
12.38 Speech therapy for delayed or abnormal speech pathology.
12.39 Substance Abuse Treatment. Treatment for chronic alcoholism and chronic drug addiction, except
those services offered as a basic health service. See Section 11.13.
12.40 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and vascular grafts. Dental
appliances, other corrective lenses and hearing aids, including the professional fee for fitting them, are
not covered.
)
.j
)
12.41 Temporomandibular Joint Dysfunction (TMJ). Services related to the diagnosis/treatment of TMJ
except when Medically Necessary; all dental treatment for TMJ.
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12.42 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to
applicable State and Federal laws or as specified in the Elective Termination of Pregnancy amendment
to the Subscribing Group Contract.
12.43 Travel expenses including expenses for ambulance services to and from a physician or Hospital except
in accordance with Section 10.01.
12.44 Treatment for armed forces service-connected medieal eare (for both sickness and injury).
12.45 Treatment ofa condition resulting from:
o
Participation in a riot or rebellion;
Engagement in an illegal occupation;
Your participation in, or commission of, any act punishable by law as a felony whether or
not you are charged or convicted.
12.46 Ventilator dependent eare, except as provided in Part X (Schedule of Basic Benefits) for ]00 days
lifetirne maximurn benefit.
12.45.01
12.45.02
12.45.03
12.4 7 Workers' Compensation benefits. Any sickness or injury for which the covered person is paid
benefits, or may be paid benefits if claimed, if the covered person is covered or required to be covered
by Workers' Compensation. In addition, if the covered person enters into a settlement giving up rights
to recover past or future medical benefits under a Workers' Compensation law, AvMed shall not cover
past or future Medical Services that are the subject of or related to that settlement. Furthermore, if the
covered person is covered by a Worker's Compensation program that limits benefits if other than
specified health care providers are used and the covered person receives care or services from a health
care provider not specified by the prograrn, AvMed shall not cover the balance of any costs remaining
) after the program has paid.
XIlI. COORDINATION OF BENEFITS
I
I l
13.0 I The services and benefits provided under this Contract are not intended to and do not duplicate any
benefit to which Members are entitled under any other Group Health Insurance, HMO, personal injury
protection and medical payments under the automobile insurance laws of this or any other jurisdiction,
governmental organization, agency, or any other entity providing health or accident benefits to a
Member, including hut not limited to: Medicare, Worker's Compensation, Public Health Service,
Champus, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or law.
AvMed coverage will be primary to Medicaid and Children's Health Insurance Program (CHIP)
benefits.
13.02 If any covered person is eligible for services or benefits under 2 or more plans as set forth in Section
13.01, the coverage under those plans will be coordinated so that up to but not more than 100% of any
eligible expense will be paid for or provided by all such plans cornbined. The Member shall execute
and deliver such instruments and papers as rnay be required and do whatever else is necessary to secure
such rights to AvMed. Failure to do so will result in nonpayment of Claims. Requested information
. should be provided to AvMed within 30 days of request or Member will be responsible for payment of
the Claim. Information received after one year from date of service will not be considered.
13.03 The standards governing the coordination of benefits are the following, pursuant to the provisions of
Chapter 627.4235, Florida Statutes:
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13.03.01 The benefits of a policy or plan that covers the person as an ernployee, member, or
subscriber, other than as a dependent, are determined before those of the policy or plan
which covers the person as a dependent.
13.03.02 Except as stated in Subsection 13.03.03, when 2 or more policies or plans cover the same
child as a dependent of different parents:
a) The benefits of the policy or plan of the parent whose birthday, excluding year of birth,
falls earlier in a year are determined before the benefits of the policy or plan of the
parent whose birthday, excluding year of birth, falls later in the year; but
b) If both parents have the same birthday, the benefits of the policy or plan which covered
the parent for a longer period oftirne are determined before those of the policy or plan
which covered the parent for a shorter period of time.
c) However, if a policy or plan subject to the rule based on the birthday of the parents as
stated above coordinates with an out-of-state policy or plan which contains provisions
under which the benefits of a policy or plan which covers a person as a dependent of a
male are determined before those of a policy or plan which covers the person as a
dependent of a female and if, as a result, the policies or plans do not agree on the order
of benefits, the provisions of the other policy or plan shall determine the order of
benefits.
13.03.03 If 2 or more policies or plans cover a dependent child of divorced or separated parents,
benefits for the child are determined in this order:
)
-J
a) First, the policy or plan of the parent with custody of the child;
b) Second, the policy or plan of the spouse of the parent with custody of the child; and
c) Third, the policy or plan of the parent not having custody of the child.
d) However, if the specific terms of a court order state that one of the parents is
responsible for the health care expenses of the child and if the entity obliged to payor
provide the benefits of the policy or plan of that parent has actual knowledge of those
terms, the benefits of that policy or plan are determined first. This does not apply with
respect to any claim determination period or plan or policy year during which any
benefits are actually paid or provided before that entity has that actual knowledge.
13.03.04 The benefits of a policy or plan which covers a person as an employee who is neither laid off
nor retired, or as that employee's dependent, are determined before those of a policy or plan
which covers that person as a laid off or retired ernployee or as that employee's dependent.
If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans
do not agree on the order of benefits, this Subsection shall not apply.
13.03.05 If none of the rules in Subsections 13.03.01, 13.03.02, 13.03.03, or 13.03.04 determine the
order of benefits, the benefits of the policy or plan which covered an employee, rnember, or
subscriber for a longer period of tirne are determined before those of the policy or plan
which covered that person for the shorter period of time.
13.03.06 Coordination of benefits shall not be permitted against an indemnity-type policy, an excess
insurance policy as defmed in Chapter 627.635, F/orida Statutes, a policy with coverage
limited to specified illnesses or accidents, or a Medicare supplement policy. However, if the
person is also a Medicare beneficiary, and if the rule established under the Social Security
Act of 1965, as amended, makes Medicare secondary to the plan covering the person as a
dependent of an active employee, the order of benefit determination is:
)
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)
a) First, benefits of a plan covering a person as an employee, member, or subscriber.
h) Second, benefits of a plan of an active worker covering a person as a dependent.
c) Third, Medicare benefits.
13.03.07 If an individual is covered under a COBRA continuation plan as a result of the purchase of
coverage as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987
(Pub.L. No. 99-272), and also under another Group Health Insurance plan, the following
order of benefits applies:
a) First, the plan covering the person as an employee or as the employee's dependent.
h) Second, the coverage purchased under the plan covering the person as a former
employee, or as the former employee's dependent provided according to the provisions
of COBRA.
13.04 For the purpose of determining the applicability and implementing the terms of the Coordination of
Benefits provision of this Contract, AvMed may, without the consent of or notice to any person, release
to or obtain from any other insurance company, organizations or person, any information, with respect
to any Subscriber or applicant for subscription, which AvMed deems to be necessary for such purposes.
13.05 Whenever payments which should have been made under this Plan in accordance with this provision
have been made under any other plans, AvMed shall have the right, exercisable alone and in its sole
discretion, to pay over to any organizations making such other payments any amounts AvMed shall
determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be
deerned to be benefits paid under this Plan.
13.06 All treatments must be Medically Necessary and cornply with all terms, conditions, Limitations, and
Exclusions of this Plan even if AvMed is secondary to other coverage and the treatment is covered under
the other coverage.
13.07 Ifthe amount of the payments made by AvMed is more than it should have paid under the provisions of
this Part XIII, it may recover the excess from one or more of the persons it has paid or for whom it has
paid; or any other person or organization that may be responsible for the benefits or services provided
for the Member. The 'amount of the payments made' includes the reasonable cash value of any benefits
provided in the form of services.
13.08 In the event the Subscribing Group offers Health Reimbursernent Arrangernents (HRA) in connection
with this Plan, the HRA is intended to pay solely for otherwise un-reirnhursed medical expenses.
Accordingly, it shall not be considered a group health plan .for coordination of benefits purposes, and its
benefits shall not be taken into account when detennining benefits payable under any other plan.
XIV. SUBROGATION AND RIGHT OF RECOVERY
If AvMed provides health care benefits under this Contract to a Member for injuries or illness for which another
party is or may be responsible, then AvMed retains the right to repayment of the full cost of all benefits provided
by AvMed on behalf of the Member that are associated with the injury or illness for which another party is or
may be responsible. AvMed's rights of recovery apply to any recoveries made by or on behalf of the Mernber
from the following third-party sources, as allowed by law, including but not limited to: payrnents made by a
third-party tortfeasor or any insurance cornpany on behalf of the third-party tortfeasor; any payments or awards
under an uninsured or underinsured motorist coverage policy; any worker's compensation or disability award or
settlement; medical payments coverage under any automobile policy, premises or homeowners medical
payments coverage or premises or homeowners insurance coverage; any other payments from a source intended
36
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to compensate a Member for injuries resulting from an accident or alleged negligence. For purposes of this
Contract, a tortfeasor is any party who has committed injury, or wrongful act done willingly, negligently or in
circumstances involving strict liability, but not including breach of contract for which a civil suit can be brought.
14.01 Member specifically acknowledges AvMed's right of subrogation. When AvMed provides health care
benefits for injuries or illnesses for which a third party is or rnay be responsible, AvMed shall be
subrogated to the Member's rights of recovery against any party to the extent of the full cost of all
benefits provided by AvMed, to the fullest extent permitted by law. AvMed may proceed against any
party with or without the Member's consent.
14.02 Mernber also specifically acknowledges AvMed's right ofreirnbursement. This right of reimbursement
attaches, to the fullest extent permitted by law, when AvMed has provided health care benefits for
injuries or illness for which another party is or may be responsible and the Member and/or the
Member's representative has recovered any amounts from the third party or any party rnaking payments
on the third party's behalf. By providing any benefit under this Contract, AvMed is granted an
assignment of the proceeds of any settlement, judgrnent or other payment received by the Member to the
extent of the full cost of all benefits provided by AvMed. AvMed's right of reimbursement is
cumulative with and not exclusive of AvMed's suhrogation right and AvMed may choose to exercise
either or both rights of recovery.
14.03 Member and the Member's representatives further agree to:
14.03.01 NotifY AvMed promptly and in writing when notice is given to any third party of the
intention to investigate or pursue a claim to recover damages or obtain compensation due to
injuries or illness sustained by the Member that may be the legal responsibility of a third
party; and
14.03.02 Cooperate with AvMed and do whatever is necessary to secure AvMed's rights of
subrogation and/or reimbursement under this Contract; and
14.03.03 Give AvMed a first-priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third party to the extent of the full cost of all
benefits associated with injuries or illness provided by AvMed for which a third party is or
rnay be responsible (regardless of whether specifically set forth in the recovery, settlement,
judgment or cornpensation agreernent); and
14.03.04 Pay, as the first priority, from any recovery, settlernent or judgment or other source of
cornpensation, any and all amounts due AvMed as reimbursement for the full cost of all
benefits associated with injuries or illness provided by AvMed for which a third party is or
may be responsible (regardless of whether specifically set forth in the recovery, settlernent,
judgment, or compensation agreement), unless otherwise agreed to by AvMed in writing; and
14.03.05 Do nothing to prejudice AvMed's rights as set forth above. This includes, but is not limited
to, refraining from rnaking any settlement or recovery, which specifically attempts to reduce
or exclude the full cost of all benefits, provided by AvMed.
14.04 AvMed rnay recover the full cost of all benefits provided by AvMed under this Contract without regard
to any claim of fault on the part of the Mernber, whether by comparative negligence or otherwise. No
court costs or attorney fees may be deducted from AvMed's recovery without the prior express written
consent of AvMed. In the event the Member or the Mernber's representative fails to cooperate with
AvMed, the Member shall be responsible for all benefits paid by AvMed in addition to costs and
attorney's fees incurred by AvMed in obtaining repayment.
)
:)
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) XV. DISCLAIMER OF LIABILITY
)
15.01 Neither Subscribing Group nor its agents, servants or employees, nor any Member is the agent or
representative of AvMed, and none of them shall be liable for any acts or omissions of AvMed, its
agents or employees or of a Participating Hospital, or a Participating Physician, or any other person or
organization with which AvMed has made or hereafter shall make arrangernents for the performance of
services under this Contract.
15.02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to AvMed or
Participating Providers except as specifically set forth herein, provided all procedures set forth herein
are followed.
15.03 Neither AvMed nor its agents, servants or employees, nor any Member is the agent or representative of
the Subscribing Group, and none of them shall be liable for any acts or omissions of Subscribing Group,
its agents or employees or any other person representing or acting on behalf of Subscribing Group.
15.04 AvMed does not directly employ any practicing physicians nor any Hospital personnel or physicians.
These health care providers are independent contractors and are not the agents or employees of AvMed.
AvMed shall be deemed not to be a health care provider with respect to any services performed or
rendered by any such independent contractors. Participating Providers maintain the physician/patient
relationship with Members and are solely responsible for all Medical Services which Participating
Providers render to Members. Therefore, AvMed shall not be liable for any negligent act or omission
committed by any independent practicing physicians, nurses, or medical personnel, nor any Hospital or
health care facility, its personnel, other health care professionals or any of their employees or agents
who may, from time to time, provide Medical Services to a Member of AvMed. Furthermore, AvMed
shall not be vicariously liable for any negligent act or omission of any of these independent health care
professionals who treat a Member of AvMed.
15.05 Certain Members may, for personal reasons, refuse to accept procedures or treatment recommended by
Participating Physicians. Participating Physicians rnay regard such refusal to accept their
recommendations as incompatible with the continuance of the physician/patient relationship and as
obstructing the provision of proper medical care. If a Member refuses to accept the medical treatment
or procedure recommended by the Participating Physician and if, in the judgment of the Participating
Physician, no professionally acceptable alternative exists or if an alternative treatment does exist but is
not recommended by the Participating Physician, the Member shall be so advised.
15.06 Ifthe Member continues to refuse the recommended treatment or procedure, AvMed may terminate the
Member's coverage under this Contract as set forth in Part IX, Subsection 9.01.05.
III
)
XVI. GRIEVANCE PROCEDURE
A grievance is any complaint other than one that involves a request (Claim) for benefits, or an appeal as
described in Section 16.02, below. Members have the right to a review of any complaint regarding the services
or benefits covered under this Plan. AvMed encourages the informal resolution of cornplaints. If you have a
complaint, you or someone you name to act on your behalf (your authorized representative) rnay call AvMed's
Member Services Department, and a Member Services Representative will try to resolve your cornplaint for you
over the phone. If you ask for a written response, or if the complaint is related to quality of care, AvMed will
respond to you in writing. The Member Services Department can also tell you how to name your authorized
representative. If a Member's complaint carmot be resolved informally (over the telephone), the complaint may
be submitted to AvMed in writing, through the formal Member grievance process. The procedures for filing a
grievance are described in 16.01, below.
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If a Member has a complaint involving a Claim for benefits, including a benefit denial, he or she may file a
written appeal with AvMed. The procedures for filing an appeal are described below, beginning with Section
16.D2.
)
16.01 Grievances relating to plan services:
16.01.01 If a Member's complaint cannot be resolved informally over the telephone, the cornplaint
may be subrnitted in writing to AvMed's Member Services Department. We call this 'filing a
grievance'. Grievances must be filed within one year of the occurrence of the event or action
that led to the grievance. We will acknowledge and investigate the grievance, and provide a
written response advising of the disposition of the grievance within 60 days after receipt of
the written grievance. You may submit a grievance in writing to;
AvMed Member Services - North AvMed Member Services - South
P.O. Box 823 P.O. Box 569008
Gainesville, Florida 32602-0823 Miami, Florida 33156-9906
Telephone: 1-800-882-8633 Telephone: 1-800-882-8633
Fax: (352) 337-8612 Fax: (305) 671-4736
.)
16.01.02 If you are not satisfied with AvMed's final decision, you may contact the Agency for Health
Care Administration (AHCA) or the Department of Financial Services (DFS) in writing
within 365 days ofreceipt of AvMed's fmal decision letter. If you appeal AvMed's decision,
your grievance will be reviewed by the Subscriber Assistance Program. You also have the
right to contact AHCA or DFS at any time to inform them of an, unresolved grievance.
a) The Subscriber Assistance Program will not hear a grievance if you have not cornpleted
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. If you need further assistance, you may contact;
Subscriber Assistance Program (SAP) Florida Department of Financial Services
Agency for Health Care Adrninistration 200 East Gaines Street
HMO Section Tallahassee, Florida 32399
2727 Mahan Drive, Mail Stop 26 Telephone 1-800-342-2762
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
)
16.02 Pre-Service Claims.
16.02.01 Initial Claim. A Pre-Service Claim shall be deemed to be filed on the date received by
AvMed. AvMed shall notifY the Claimant of the benefit de!ermination (whether adverse or
not) within a reasonable period of time appropriate to the medical circumstances, but not
later than 15 days after AvMed receives the Pre-Service Claim. AvMed may extend this
period one time for up to 15 days, provided that AvMed determines that such an extension is
necessary due to matters beyond AvMed's control and notifies the Claimant, before the
expiration of the initial 15-day period, of the circumstances requiring the extension of time
and the date by which AvMed expects to render a decision. If such an extension is necessary
because the Claimant failed to submit the information necessary to decide the Claim, the
notice of extension shall specifically describe the required information, and the Claimant
shall be afforded at least 45 days frorn receipt of the notice within which to provide the
specified information. In the case of a failure by a Claimant to follow AvMed's procedures
for filing a Pre-Service Claim, the Claimant shall be notified of the failure and the proper
procedures to be followed in filing a Claim for benefits not later than 5 days following such
failure. AvMed's period for making the benefit determination shall be tolled from the date on
39
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)
which the notification of the extension is sent to the Clairnant until the date on which the
Claimant responds to the request for additional information. If the Claimant fails to supply
the requested information within the 45-day period, the Claim shall be denied.
16.02.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Pre-
Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed
shall notify the Claimant, in accordance with Section 16.08, of its determination on review
within a reasonable period of time. Such notification shall be provided not later than 30
days after AvMed receives the Claimant's request for review of the Adverse Benefit
Determination. You may submit an appeal to:
AvMed Member Services - North AvMed Member Services - South
P.O. Box 823 P.O. Box 569008
Gainesville, Florida 32602-0823 Miami, Florida 33156-9906
Telephone: 1-800-882-8633 Telephone, 1-800-882-8633
Fax: (352) 337-8612 Fax: (305) 671-4736
16.02.03 If you are not satisfied with AvMed's final decision, you may contact AHCA or DFS in
writing within 365 days of receipt of the fmal decision letter. If you appeal AvMed's
decision, your grievance will be reviewed by the Subscriber Assistance Program. You also
have the right to contact AHCA or DFS at any time to inform them of an unresolved
grievance.
a) The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. If you need further assistance, you may contact:
o
)
Subscriber Assistance Program (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1-800-342-2762
16.03 Urgent Care Claims.
16.03.01 Initial Claim. An Urgent Care Claim shall be deemed to be filed on the date received by
AvMed. AvMed shall notify the Claimant of AvMed's benefit determination (whether
adverse or not) as soon as possible, taking into account the medical exigencies, but not later
than 72 hours after AvMed receives, either orally or in writing, the Urgent Care Claim,
unless the Claimant fails to provide sufficient information to detennine whether, or to what
extent, benefits are covered or payable under the Plan. If such information is not provided,
AvMed shall notify the Claimant as soon as possible, but not later than 24 hours after AvMed
receives the Claim, of the specific information necessary to complete the Claim. The
Claimant shall be afforded a reasonable amount of time, taking into account the
circumstances, but not less than 48 hours, to provide the specified information. AvMed shall
notify the Claimant of the benefit detennination as soon as possible, but in no case later than
48 hours after the earlier of:
a) AvMed's receipt of the specified information; or
b) The end of the period afforded the Clairnant to provide the specified additional
information.
40
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16.03.02 If the Claimant fails to supply the requested information within the 48-hour period, the
Claim shall be denied. AvMed may notify the Claimant of the benefit determination orally or
in writing. If the notification is provided orally, a written or electronic notification, meeting
the requirements of Section 16.06, shall be provided to the Claimant no later than 3 days
after the oral notification.
16.03.03 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent
Care Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall
notify the Claimant, in accordance with Section 16.08, ofAvMed's benefit determination on
review as soon as possible, taking into account the medical exigencies, but not later than 72
hours after AvMed receives the Claimant's request for review of an Adverse Benefit
Determination. You may submit an appeal to:
')
AvMed Member Services - North
P.O. Box 823
Gainesville, Florida 32602-0823
Telephone: 1-800-882-8633
Fax: (352) 337-8612
AvMed Member Services - South
P.O. Box 569008
Miami, Florida 33156-9906
Telephone: 1-800-882-8633
Fax: (305) 671-4736
1
16.03.04 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for
Health Care Administration (AHCA) or the Department of Financial Services (DFS) in
writing within 365 days of receipt of the fmal decision letter. If you appeal AvMed's
decision, your grievance will be reviewed by the Subscriber Assistance Program. You also
have the right to' contact the AHCA or DFS at any time to inform them of an unresolved
grievance.
a) The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. If you need further assistance, you may contact:
Subscriber Assistance Program (SAP) Florida Department of Financial Services
Agency for Health Care Administration 200 East Gaines Street
HMO Section Tallahassee, Florida 32399
2727 Mahan Drive, Mail Stop 26 Telephone 1-800-342-2762
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
)
16.04 Concurrent Care Claims
16.04.01 Any reduction or termination by AvMed ofConcUITent Care (other than by Plan amendment
or termination) before the end of an approved period of time or number of treatments, shall
constitute an Adverse Benefit Determination. AvMed shall notify the Claimant, in
accordance with Section 16.06, of the Adverse Benefit Determination at a time sufficiently
in advance of the reduction or termination to allow the Clairnant to appeal and obtain a
determination on review of the Adverse Benefit Determination before the benefit is reduced
or terminated.
16.04.02 Any request by a Claimant to extend the course of treatment beyond the period of time or
number of treatments that relates to an Urgent Care Claim shall be decided as soon as
possible, taking into account the rnedical exigencies, and AvMed shall notify the Claimant of
the benefit determination, whether adverse or not, within 24 hours after Av Med receives the
Claim, provided that any such Claim is made to AvMed at least 24 hours before the
expiration of the prescribed period of time or number of treatments. Notification and appeal
41
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I
I')
) of any Adverse Benefit Determination concerning a request to extend the course of
treatment, whether involving an Urgent Care Claim or not, shall be made in accordance with
the remainder of Part XVI.
o
16.05 Post-Service Claims.
16.05.01 Initial Claim. A Post-Service Claim shall be deemed to be filed on the date received by
AvMed. AvMed shall notify the Claimant, in accordance with Section 16.06 of AvMed's
Adverse Benefit Determination within a reasonable period of time, but not later than 30 days
after AvMed receives the Post-Service Claim. AvMed may extend this period one time for up
to 15 days, provided that AvMed determines that such an extension is necessary due to
matters beyond AvMed's control and notifies the Claimant, before the expiration of the
initial 30-day period, of the circumstances requiring the extension of time and the date by
which AvMed expects to render a decision. If such an extension is necessary because the
Claimant failed to submit the information necessary to decide the Post-Service Claim, the
notice of extension shall specifically describe the required information, and the Claimant
shall be afforded at least 45 days from receipt of the notice within which to provide the
specified information. AvMed's period for making the benefit determination shall be tolled
from the date on which the notification of the extension is sent to the Claimant until the date
on which the Claimant responds to the request for additional information. If the Claimant
fails to supply the requested information within the 45-day period, the Claim shall be denied.
16.05.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Post-
Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed
shall notify the Clairnant, in accordance with Section 16.08, of AvMed's determination on
. review within a reasonable period oftime. Such notification shall be provided not later than
60 days after AvMed receives the Clairnant's request for review of the Adverse Benefit
Determination. You rnay submit an appeal to:
)
AvMed Mernber Services - North
P.O. Box 823
Gainesville, Florida 32602-0823
Telephone: 1-800-882-8633
Fax: (352) 337-8612
AvMed Member Services - South
P.O. Box 569008
Miami, Florida 33156-9906
Telephone: 1-800-882-8633
Fax: (305) 671-4736
16.05.03 If you are not satisfied with AvMed's final decision, you rnay contact AHCA or DFS in
writing within 365 days of receipt of the final decision letter. If you appeal AvMed's
decision, your grievance will be reviewed by the Subscriber Assistance Program. You also
have the right to contact AHCA or DFS at any time to inform them of an unresolved
grievance.
a) The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. If you need further assistance, you may contact:
Subscriber Assistance Program (SAP) Florida Department of Financial Services
Agency for Health Care Administration 200 East Gaines Street
HMO Section Tallahassee, Florida 32399
2727 Mahan Drive, Mail Stop 26 Telephone 1-800-342-2762
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
42
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16.06 Manner and content of initial claims determination notification. AvMed shall provide a Claimant
with written or electronic notification of any Adverse Benefit Determination. The notification shall set
forth, in a manner calculated to be understood by the Claimant, the following:
')
The specific reasons for the Adverse Benefit Determination.
Reference to the specific Plan provisions on which the determination is based.
A description of any additional material or information necessary for the Claimant to perfect
the Claim and an explanation of why such material or irtforrnation is necessary.
A description of AvMed's review procedures and the time limits applicable to such
procedures, including, when applicable, a statement of the Claimant's right to bring a civil
action under Section 502(a) of the Employee Retirement Income Security Act of 1974, as
amended (ERISA), following an Adverse Benefit Determination on final review.
16.06.05 If an internal rule, guideline, protocol, or other similar criterion was relied upon in making
the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other
similar criterion or a statement that such rule, guideline, protocol or other similar criterion
was relied upon in rnaking the Adverse Benefit Determination and that a copy shall be
provided free of charge to the Claimant upon request.
16.06.06 If the Adverse Benefit Determination is based on whether the treatment or service is
experimental and/or investigational or not Medically Necessary, either an explanation of the
scientific or clinical judgment for the determination, applying the teffilS of the Plan to the
Claimant's medical circumstances, or a staternent that such explanation shall be provided
free of charge upon request.
16.06.07 In the case of an Adverse Benefit Determination involving an Urgent Care Clairn, a
description of the expedited review process applicable to such Claim.
16.07 Review procedure upon appeal. AvMed's appeal procedures shall include the following substantive
procedures and safeguards:
16.06.01
16.06.02
16.06.03
16.06.04
-j
)
16.07.01 Claimant may submit written comments, documents, records, and other information relating
to the Claim.
16.07.02 Upon request and free of charge, the Claimant shall have reasonable access to and copies of
any Relevant Documents.
16.07.03 The appeal shall take into account all comments, documents, records, and other information
the Claimant submitted relating to the Claim, without regard to whether such information
was submitted or considered in the initial Adverse Benefit Determination.
16.07.04 The appeal shall be conducted by an appropriate named fiduciary of AvMed who is neither
the individual who made the initial Adverse Benefit Determination nor the subordinate of
such individual. Such person shall not defer to the initial Adverse Benefit Determination.
16.07.05 In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part
on a medical judgment, including determinations with regard to whether a particular
treatment, medication, or other itern is experimental and/or investigational or not Medically
Necessary, the appropriate named fiduciary shall consult with a Health Professional who has
appropriate training and experience in the field of medicine involved in the medical
judgment.
16.07.06 The appeal shall provide for the identification of medical or vocational experts whose advice
was obtained on behalf of AvMed in connection with a Claimant's Adverse Benefit
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o
) Determination, without regard to whether the advice was relied upon in making the Adverse
Benefit Determination.
16.07.07 The appeal shall provide that the Health Professional engaged for purposes ofa consultation
in Subsection 16.07.05 shall be an individual who is neither an individual who was
consulted in connection with the initial Adverse Benefit Determination that is the subject of
the appeal, nor the subordinate of any such individual.
16.07.08 In the case of an Urgent Care Claim, there shall be an expedited review process pursuant to
which:
a) Request for an expedited appeal of an Adverse Benefit Determination may be submitted
orally or in writing by the Claimant; and
b) All necessary information, including AvMed's benefit determination on review, shall be
transmitted between AvMed and the Claimant by telephone, facsimile, or other
available similarly expeditious methods.
16.08 Manner and content of appeal notification. AvMed shall provide a Claimant with written or
electronic notification ofAvMed's benefit determination upon review.
16.08.0] In the case of an Adverse Benefit Determination, the notification shall set forth, in a manner
calculated to be understood by the Claimant, all of the following, as appropriate:
a) The specific reasons for the Adverse Benefit Determination.
b) Reference to the specific Plan provisions on which the Adverse Benefit Determination
is based.
c) A statement that the Clairnant is entitled to receive, upon request, and free of charge,
reasonable access to, and copies of any Relevant Documents.
)
d) A statement describing any voluntary appeal procedures offered by AvMed and the
Claimant's right to obtain the information about such procedures and a statement of the
Claimant's right to bring an action under ERISA Section 502(a) when applicable.
e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in
making tbe Adverse Benefit Determination, either the specific rule, guideline, protocol,
or other similar criterion or a statement that such rule, guideline, protocol, or other
similar criterion was relied upon in rnaking the Adverse Benefit Determination and that
a copy shall be provided free of charge.to the Claimant upon request.
f) If the Adverse Benefit Determination is based on whether the treatment or service is
experimental and/or investigational or not Medically Necessary, either an explanation
of the scientific or clinical judgment for the determination, applying the terms of the
Plan to the Claimant's rnedical circumstances, or a statement that such explanation shall
be provided free of charge upon request.
XVII. MISCELLANEOUS
17.0 I Applicability of law. The provisions of this Contract shall be deemed to have been modified by the
parties, and shall be interpreted, so as to comply with the Jaws and regulations of the State of Florida
and the United States.
44
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)
17.02 Assignment. This Contract, and all rights and benefits related thereto, may not be assigned by the
Subscribing Group or the Members without written consent of AvMed.
17.03 Certificate of Coverage. AvMed shall provide a copy of the Certificate of Coverage for each Subscriber.
No changes or amendments to this Contract shall be valid unless approved by an executive officer of
AvMed and endorsed herein or attached hereto. No agent has authority to change this Contract or to
waive any of its provisions.
17.04 Circumstances not reasonably within the control of AvMed. In the event of circumstances not
reasonably within the control of AvMed, including major disasters and under such circumstances as
complete or partial destruction of facilities, an act of God, war, riot, civil insurrection, disability of a
significant part of Hospital or participating medical personnel or similar causes, if the rendition of
Medical Services and Hospital Services provided under this Contract is delayed or rendered impractical,
neither AvMed, Participating Providers, nor any physician shall have any liability or obligation on
account of such delay or failure to provide services; however, AvMed shall make a good faith effort to
arrange for the timely provision of covered services during such event.
17.05 Clerical errors. Clerical errors shall neither deprive any individual Member of any benefits or coverage
provided under this Group Contract nor shall such errors act as authorization of benefits or coverage for
the Mernber that is not otherwise validly in force. Retroactive adjustments in-coverage, for clerical
errors or otherwise will only be done for up to a 60 day period from the date of notification. Refunds of
premiums are done for up to a 60 day period frorn the date of notification. Refunds of prerniums are
limited to a total of 60 days from the date of notification of the event, provided there are no Claims
incurred subsequent to the effective date of such event.
17.06 Contracting parties. By executing this Contract, Subscribing Group and AvMed agree to make the
Medical Services and Hospital Services specified herein available to persons who are eligible under the
provisions of Part IV. However, the delivery of benefits and services covered in this Contract shall be
subject to the provisions, Limitations, and Exclusions set forth herein and any amendments,
modifications, and Contract termination provisions specified herein and by the mutual agreement
between AvMed and Subscribing Group, without the consent or concurrence of the Members. By
electing or accepting Medical Services and Hospital or other benefits hereunder, all Members legally
capable of contracting and the legal representatives of all Members incapable of contracting, agree to all
terms, conditions, and provisions hereof.
17.07 Contract review. Subscribing Group may, if this Contract is not satisfactory for any reason, return this
Contract within 3 days after receipt and receive a full refund of the deposit paid, if any, unless the
services of AvMed were utilized during the 3 days. If this Contract is not returned within 3 days after
receipt, then this Contract shall be deemed to have heen accepted.
17.08 Entirety of Contract. This Agreement and all applicable schedules, exhibits, riders, amendments and
any other attachments and endorsernents, constitute the entire Contract between the Subscribing Group
and AvMed. No modification (or oral representation) of this Group Contract shall be of any force or
effect unless it is in writing and signed by both parties.
17.09 ERlSA. When this Contract is purchased by the Subscribing Group to provide benefits under a welfare
plan governed by ERlSA, AvMed shall be considered a fiduciary to the extent that it perfonns any
discretionary functions on behalf ofthe Plan. If a Member has questions about the group's welfare plan,
the Mernber should contact the Subscribing Group.
17.10 Gender. Whenever used, the singular shall include the plural and the plural the singular and the use of
any gender shall include all genders.
17.11 Identification cards. Cards issued by AvMed to Members pursuant to this Contract are for purposes of
identification only. Possession of an AvMed identification card confers no right to health services or
)
)
)
45
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")
;)
) other benefits under this Contract. To be entitled to such services or benefits the holder of the card
must, in fact, be a Member on whose behalf all applicable charges under this Contract have actually
been paid and accepted by AvMed.
17.12 Membership Application. Members or applicants for membership shall complete and submit to AvMed
such applications or other forms or statements as AvMed may reasonably request. If Member or
applicant fails to provide accurate information which AvMed deems material then, upon ten days written'
notice, AvMed may deny coverage andlor membership to such individual. Any person who knowingly
and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application
containing any false, incomplete, or misleading information is guilty of a felony, punishable as provided
by the Florida Statutes.
17.13 Non-waiver. The failure of AvMed to enforce any of the provisions of this Contract or to exercise any
options herein provided or to require timely performance by any Member or Subscribing Group of any
of the provisions herein, shall not be construed to be a waiver of such provisions nor shall it affect the
validity of this Contract or any part thereof or the right of Av Med to thereafter enforce each and every
such provision.
17.14 Notice. Any notice intended for and directed to a party to this Contract, unless otherwise expressly
provided, should be sent by United States mail, postage prepaid, addressed as follows:
If to AvMed, to: AvMed
P. O. Box 749
Gainesville, Florida 32602-0749
(OR if from a Member to AvMed, see the Member's Service Area address listed on Page i.)
If to a Member: to the last address provided by the Member and actually received by AvMed on the
emollment application or change of address notification.
If to Subscribing Group: To the address provided in the Group Master Application.
17.15 Plan administration. AvMed may from time to time adopt reasonable policies, procedures, rules, and
interpretations to promote the orderly and efficient administration of this Contract.
17.16 Premium tax/surcharge. If any govermnent entity shall impose a premium tax or surcharge, then the
sums due from the Subscribing Group under the terms of this Contract shall be increased by the amount
of such premium tax or surcharge.
)
17.17 Rate letter. The 'rate letter' is AvMed's formal notice to the Subscribing Group of the premium rates
applicable to the Subscribing Group, the conditions under which the rates are valid, the premium
payment terms and due dates, the additional charge which will apply to all late premium payments,
AvMed's reservation of the right to adjust (re-rate) the premium quote to account for changes in the
group size or in the data supplied by the Subscribing Group to AvMed, the applicable employer-
employee contribution to the premium payment and the charge for other optional, supplemental benefits
selected by the Subscribing Group, if any.
17.18 Third party beneficiary. This Contract is entered into exclusively between the Subscribing Group and
AvMed. This Contract is intended only to benefit the ~ubscribing Group and the Members and does not
confer any rights on any other third parties.
17.19 Waiver. A Claim that has not been timely filed with AvMed within one year of date of service shall be
considered waived.
46
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')
AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application
AvMED
HUAL1'1I PLANS
Contract Number(s):
Subscribing Group Name:
Effective Date:
108496
City of Sunny Isles Beach
03/01/10
Group Contract
This Group Contract provides the benefits listed below:
q
Identifier
AV-LG-l 0/150/750/1 0%-09
AV-Deductible/Co-insurance Amendment-09
AV-Open Acess-09
A V-LG-RX-2x-l0/20/30/75/50%-OC-B-09
AV-Gl00-MHPH-09
AV-Gl00-SAPH-09
A V-Gl00-ETP-R-97
AV-Mamm09ram-05
Descriotion
Summary of Benefits
Ded & Co-ins
Open Access
Prescription Drug
IP Mental Health
Substance Abuse
ETOP
Mammogram
Eliaibilitv
Active Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this Contract.
Employees will become eligible for coverage on the first of the month following the first day of employment.
Management Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this
Contract. Employees will become eligible for coverage on the first of the month following the first day of employment.
Termination
For Active Employees (Class 1), termination of coverage under this Contract shall become effective End of Month.
For Management Employees (Class 1), termination of coverage under this Contract shall become effective End of Month.
Monthlv MembershiD Charaes
Subscriber plus Spouse and One or More Dependents.
$470.17
$1,043.78
$879.08
$879 08
$1,330.30
Subscriber Only.........................
Subscriber plus Spouse
Subscriber plus One Dependent (No Spouse) ....
Subscriber plus Two or More Dependents ....................
AV-Masler Application-07
MP-2027 (1107)
I,
")
AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
Aareement
This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital
services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED, Ino.
d/b/a AVMED Health Plans and the Subscribin9 Group, This Contract shall remain in effect for a period of twelve (12)
months from the effective date of March 1, 2010 and may be renewed annually, not later than the anniversary date, upon
mutual agreement of the parties. This Contract period begins at 12:01 a.m. Eastern Standard Time on the effective date or
on the anniversary date, if a renewal. The Contract shall be governed by Chapter 641, Florida Statutes, and other applicable
State and Federal laws.
The first monthly payment is due on March 1, 2010. Subsequent payments are due on the 1st day of each month
o thereafter,
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
The provisions contained in the Schedule of Benefits applicable to this Contract and all Exhibits and Amendments executed
by the parties and attached hereto are, by reference, made a part of this Contract.
AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written.
By:
::"2J;;(M/fI
( Signature
-
12.\l,\L CortJtll-
Name
Patricia Nelson
Name
CI1 M~t,~(L
Title
~I.l\..--i I, ~IO
Director of Client Services
Date:
Date:
G/I 0 !~eU
AV-Master Application.07
MP-2027 WO?)
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY
~SOTrI~ORN~
")
LARGE GROUP
$10/$250/$750/1 0%
CALENDAR YEAR
DEDUCTIBLE
OUT-Of-POCKET MAXIMUM
AVMED PRIMARY CARE
PHYSICIAN
q
MATERNITY CARE
AVMED SPECIALITY HEALTH
CARE PHYSICIAN SERVICES
HOSPITAL
OUTPATIENT SERVICES
OUTPATIENT DIAGNOSTIC
TESTS
EMERGENCY SERVICES
A V-LG-IO/250/750/10%-09
MP-5228 (10/09)
Benefit Summary
SCHEDULE OF BENEFITS
INDIVIDUAL! FAMILY
The Deductible does nol apply toward the Out-of-Pocket A1aximuI1l
INDIVIDUAL! FAMILY per calendar year
The Oul-al-Pocket A1aximlll1l includes Co-payments and Co-
insurance amounts unless othenl'ise excluded
Services at Participating Physicians' offices include, but are not
limited to:
Routine office visits/annual well-woman examination when
performed by Primary Care Physician
Pediatric care and well-child care
Periodic health evaluation and immunizations
Diagnostic imaging, laboratory or other diagnostic services
Minor surgical procedures
Vision and hearing screenings for children under 18
. Initial visit
. Subsequent visits
Office visits
Annual well-woman examination when performed by a
participating Specialty Health Care Physician
Additional charges will apply if Outpatient Diagnostic Tests are
performed in the Specialist's Office.
Inpatient care at Hospitals includes:
. Room and board - unlimited days (semi-private)
. Physicians', specialists' and surgeons' services
. Anesthesia, use of operating and recovery rooms, oxygen, drugs
and medication
. Intensive care unit and other special units, general and special
duty nursing
. Laboratory and diagnostic imaging
. Required special diets
. Radiation and inhalation therapies
. Outpatient surgeries, including cardiac catheterizations and
angioplasty
. Outpatient therapeutic services, including:
Drug infusion therapy
Injectable Drugs (Co-payment for Injectable Drug
waived if incidental to same-day drug infusion therapy)
Preventive and diagnostic colonoscopies
. One preventive colonoscopy per lifetime (Not subject to
Calendar Year Deductible)
. CAT Scan, PET Scan, MRI
. Other diagnostic imaging tests
Charges for office visits will also apply if services are performed in a
Specialist's office.
An emergency is the sudden and unexpected onset of a condition
requiring immediate medical or surgical care. (Co-payment waived
ifadmiUed)
. Emergency services at Participating Hospitals
. Emergency services at non-participating Hospitals, facilities
and/or physicians
AvMed must be notified within 24 hours of inpatient admission
following emergency services or as soon as reasonably possible.
AvMED
HEALTH PLANS
COST TO MEMBER
$2501 $750 annually
$7501 $1,500 annually
$10 per visit
$10 Co-payment
NO CHARGE
$20 per visit
$150 per admission; 100%
coverage thereafter
$150 Co-payment
$100 Co-payment
$75 Co-payment
$150 Co-payment
NO CHARGE
10% of the contracted rate,
after Deductible
$75 Co-payment
")
Benefit Summary, continued
\-)
URGENT/IMMEDIATE CARE .
.
.
FAMILY PLANNING .
.
ALLERGY TREATMENTS .
.
AMBULANCE .
.
PHYSICAL, SPEECH AND .
OCCUPATIONAL THERAPIES
Medical Services at a participating Urgent/Immediate Care
facility or services rendered after hours in your Primary Care
Physician's office
Medical Services at a participating retail clinic
Medical Services at a non-participating Urgent/Immediate Care
facility or non. participating retail clinic
Voluntary family planning services
Sterilization (In addition to any Outpatient Facility charge)
Injections
Skin testing
Ambulance transport for emergency services
Non-emergent ambulance services are covered when the skill of
medically trained personnel is required and the Member cannot
be safely transported by other means
Short-term physical, speech or occupational therapy for acute
conditions
Coverage is limited to 30 visits per calendar year for all services
combined
$40 Co-payment
$10 per visit
$60 Co-payment
$10 per visit
$250 Co-payment
$10 per visit
$50 per course of testing
$100 Co-payment
$10 per visit
$20 per visit
$10 per visit
DIAGNOSIS AND TREATMENT
OF AUTISM SPECTRUM
DISORDER
. Applied Behavior Analysis services
. Physical, speech or occupational therapy for the treatment of
Autism Spectrum Disorder
Coverage for all services related to Autism Spectrum Disorder is
limited to $36,000 annually and may not exceed $200,000 in total
benefits.
. Up to 20 days post-hospitalization care per calendar year when
prescribed by physician and authorized by A vMed
SKILLED NURSING FACILITIES
AND REHABILITATION
CENTERS
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions:
. Acute myocardial infarction
. Percutaneous transluminal coronary angioplasty (PTCA)
. Repair or replacement of heart valves
. Coronary artery bypass graft (CABG), or
. Heart transplant
Coverage is limited to 18 visits per calendar year
HOME HEALTH CARE . Limited to 60 skilled visits per calendar year
DURABLE MEDICAL
EQUIPMENT AND
ORTHOTIC APPLIANCES
Equipment includes:
Hospital beds
. Walkers
. Crutches
. Wheelchairs
Orthotic appliances are limited to:
. Leg, arm, back and neck custom~made braces
Prosthetic devices are limited to:
. Artificial limbs
Artificial joints
. Ocular prostheses
PROSTHETIC DEVICES
10% of the contracted rate,
after Deductible
$10 per visit
Benefits limited
to $1,500 per
calendar year
10% of the contracted rate,
after Deductible
10% of the contracted rate,
after Deductible
Benefits limited
to $2,000 per
calendar year
10% of the contracted rate,
after Deductible
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-800-88-AVMEO (1-800-882-8633)
This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions
and Limitations, please consult your AvMed Group Medical and Hospital Service Contract.
A V-LG.IO/2501750/10%-09
MP-5228 (10/09)
f)
Amendment
AvMED
HEALTH PLANS
Large Group. Deductible and Co-insurance
These provisions of the policy are amended as follows:
"a,tlll. DEFINITIONS, has been amended to add the following definitions:
n
. "Calendar Year" means the twelve-month period beginning January I and ending December 31.
. IICo-insurance" means the amount a covered Member must pay, once the Deductible has been met, and is
expressed as a percentage of tile allowed amount for the covered benefit.
. "Deductible" means the first payments up to a specified dollar amount, excluding Co-payments, that a
Member must make in the applicable Calendar Year for covered benefits. The Deductible applies to each
Member, subject to any family Deductible listed on the Schedule of Benefits. Fo, purposes of the
Deductible, "family" means the Subscriber and Covered Dependents. The Deductible must be satisfied once
each Calendar Year, except for:
o the Common Accident Provision: if the Deductible applies to accident expenses and if 2 or more
Members of any family receive covered benefits because of disabilities resulting from injuries
sustained in anyone accident, the Deductible will be applied only once with respect to all covered
benefits received as a result of the accident.
o the Deductible Credit Provision: any expense incurred by a Member while covered under the
group's prior carrier will be credited toward satisfaction of the Deductible under this Plan if:
o the expenses were incurred during the 90-day period before the effective date of the Group
Plan;
o the expenses were applied toward satisfaction of the Deductible under the prior coverage
during the 90-day period before the effective date of this Group Plan; and
o the expenses would be considered eligible expenses under this Group Plan.
However, in order to receive credit, you must supply evidence of satisfaction of the Deductible
under the prior coverage by providing A vMed Health Plans written proof of what has been paid by
prior carrier.
o the Carryover Provision: if any part or all of the Deductible has been satisfied during the last 3
months of the preceding Calendar Yea" the Deductible for the next Calendar year will be reduced
by the amount satisfied.
Under Pa,t VII. MONTHLY PAYMENTS AND CO-PAYMENTS, has been amended as follows:
)
7.03 Annual Maximum Out-of-Pocket Limits (as described in your Schedule of Benefits). Co-insurance and Co-payments
you pay for benefits received during any Calendar Year are accumulated toward your annual maximum out-of-pocket
limit. Once you meet your individual or family annual maximum out-of-pocket limit in any Calendar Year, AvMed will
pay 100% of the allowable charges for all covered services for the remainder of that Calendar Year. Expenses that do
not count toward the annual maximum out-of-pocket limit are expenses used to satisfy the individual or family
Deductible and any services provided under the Prescription Drug, Mental Health, Substance Abuse, Vision and other
supplemental riders.
7.04 Member shall pay premiums, applicable supplemental charges, Deductibles, Co~payments and/or Co-insurance as
provided in this Contract. If the Member fails to do so, upon ten (10) days written notice from AvMed to Member, the
Member's rights hereunder shall be terminated. Consideration for reinstatement with AvMed shall require a new
application, and any re-enrollment shall be at the sole discretion of A vMed and shall not be retroactive.
7.07 A Member will be entitled to covered benefits after the Member has satisfied the Deductible amount, if any, specified on
the Schedule of Benefits. After satisfying the Deductible, the Member must pay any applicable Co-insurance for
covered benefits. Covered benefits to which the Deductible applies are shown in the Schedule of Benefits. The
Deductible does not apply to certain covered benefits. In those instances, the Member must pay any applicable Co-
payments for covered benefits to which the Deductible does not apply.
A V-Deductible/Co-insurance Amendment.09
Mp.)647 (10109)
')
Amendment
AvMED
HEALTH PLANS
Open Access 10 Specially Heallhcare Physicians
As of the Effective Date, the introductory language of section X. Schedule of Basic Bcnefits of the
Group Medical and Hospital Service Contract is amended as follows:
Each Member may select one Primary Care Physician (PCP) upon enrollment, but is not required to
do so. In the event that you do choose a PCP, the Health Plan must be notified and you must receive
approval prior to changing your PCP. Such change will become effective on the first day of the
month after you notify Health Plan, You cannot change your PCP selection more than once per
month.
I
1(.)
I
I
,
You are entitled to see participating Specialty Hcalth Care Physicians without a referral from your
PCP. Self-referral is not permitted to participating Specialty Health Care Physicians designated as
"Requires Special Consultation between your Doctor and the A vMed Medical Director" in the written
or electronic Provider Directories at the time of service.
Health Professionals may from time to time ceaSe their affiliation with Health Plan. In such cases,
you will be required to receive services from another Participating Health Professional.
A V-Open Access-09
MP-3931 (10109)
')
Prescription Medication Benefits
AvMm'
HEALTH PLANS
n
$10/20/30n5/50% CO-PAYMENT with Contraceptives
OEFINITIONS
Brand medication means a Prescription Dmg that is usually m;:mufactured :.md sold under a n:une or trademark by a phannaceutical manufacturer or a
medication that is identified a~ a Bnmd medication by AvMed. AvMed delegates detennination of GenericIBrnnd status to our Phannacy Benefits Manager.
Bmnd Additional Charge means the additional charge that must be paid if you choose a BidIld medication when a Generic equivalent is available. TIle
charge is the difference between the cost of the Brdlld medication and the Generic medication. This charge must be paid in addition 10 the applicable Non-
Preferred Bmnd Co-payment. However, if the prescribing physician or other Participating Provider authorized to prescribe medications within the scope of his
or her license indicates on the prescription Brand medically necessary or dispense as written for a medication for which there is a generic equivalent, the Brand
medication shall be dispensed for the applicable Non-Preferred Brcmd Co-payment only.
Cost-sharing I\ledkHliolls are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively minor
non-life threatening conditions. Such medications are subject to Co-insurance and coverage is limited as outlined below.
Dental-specific Medication is medic,\tion used for dental-specific purposes, including but not limited to fluoride medications ,md medications packaged and
labeled for dental-specific purposes.
Formulary List means the listing of prefcrred and non-prefcrred medications a'i detennined by AvMed's Pharmacy and 1l1cra~utics Committee based on
clinical efficacy, relative safety and cost in comparison to similar medications within a thcrapeutic class. This multi-tiered list establishes different levels of
Co-payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been
reviewed by AvMed's Phannacy and Therapeutics Committee.
Generic medication means a medication that has the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's
Pharmacy Benefits Manager.
Injectable Medication is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the
following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intnuticular injection,
intracavcmous injection or intraocular injection. Prior authorization is required for all Injectable Medications.
Maintenance I\kdic-dtion is a medication that has been approved by the FDA, for which the duration of therapy can rc,l'mnably be expected to exceed one
year.
Participating Phanu3cy means a pharmacy (retail, mail order or specialty phannacy) that has entered into an agreement with AvMed to provide Prescription
Drugs to AvMed Members <md has been designated by AvMed as a Participating Phannacy.
Prescription Dnlg means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and
federal law.
Prior Authon7..ation meatls the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMcd's guidelines. The
prescribing physician must obtain approval. from AvMed. The list of Prescription Drugs requiring Prior Authorization is subject to periodic review atld
modification by AvMed. A copy of the list of medications requiring Prior Authorization and the applicable criteria are available from Member Services or from
the AvMed website.
HOW DOES YOUR RETAil PRESCRIPTION COVERAGE WORK?
To obtain your Prescription Drug, take your prescription to, or have your physician call, an AvMed Participating Phannacy. Your physician should submit
prescriptions for Injectable Medications to AvMed's specialty phannacy. Present your prescription along with your AvMed identification card. Pay the
following Co-payment (as well as the Brand Additional Charge if you choose a Brand product when a Generic equivalent is available).
lier I. Preferred Generic Medications:
lier 2 Prefcrred Brand Medications:
lier 3 Non~Prcferred Bnmd or Generic Medications:
lier 4 Injectable Medications:
lier 5 Cost.sharing Medications:
OROERING YOUR PRESCRIPTIONS THROUGH THE MAil
Mail service is a benefit option for maintenance medications needed for chronic or long-tenn health conditions. It is best to get an initial prescription filled at
your retail pharmacy. Ask your physician for ,m additional. prescription for up to a 90-day supply of your medication to be ordered through mail service. Up to
3 refills are allowed per prescription. Pay the following Co-payment (as well as the Brcmd Additional Charge if you choose a Brand product when a Generic
equivalent is available).
$ 10.00
$ 20.00
$ 30.00
$ 75.00
50%
Co-payment
Co-payment
Co-payment
Co-payment
Co-Insurance
lier I
lierZ
lier3
lier4
lier 5
$
$
Non-Prefen"ed Brand or Generic Medications: $
Injectable Medications are not available through mail. service
Cost-sharing Medications are not available through mail service
20.00
40.00
60.00
Co-payment
Co-payment
Co-payment
Preferred Generic Medications:
Preferred Brand Medications:
A V .LG-RX-2x-1 0I20/30n5/50%-B.09
MP-4000 (10/09)
I')
Prescription Medication Benefits, continued
WHAT IS COVEREO?
. Your Prescription Drug covemge includes outpatient medications (including contraceptives) that require a prescription and arc prescribed by your AvMed
physician in accordance with AvMed's covernge criteria. AvMed reserves the right to make changes in covemge criteria for covered products and services.
Coverage criteria are medical ,md pharmaceutical protocols used to dctennine payment of products and services and are based on independent clinical
pmcticc guidelines and standards of care established by government agencies and mcdicallph.mnaccutical societies.
. Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Progrrun. for certain covered medications. The
Progressive Medication Progmm encourages the use of therapeutically-equivalent lower-cost medications by requiring certain medications to be utilized to
treat a medical condition prior to approving another medication for that condition. This includes the first-line use of preferred medications that are proven to
be safe and effective for a given condition and can provide the same health benefit as more expensive non-preferred medications at a lower cost.
. Your retail Prescription Dmg coverage includes up to a 3D-day supply of a medication for the listed Co-payment. Your prescription may be refilled via
retail or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have the opportunity to obtain a
90-day supply of medications used for chronic conditions including, but not limited to a<;thma, cardiovascular disea<;e, and diabetes from the retail
pharmacy for the applicable Co-payment per 3D-day supply. However, Prior Authorization may be required for covered medications.
. Your mail-order Prescription Drug coverage includes up to a 90-day supply of a routine maintenance medication for the listed Co-payment. If the amount
of medication is less than a 90-day supply, you will still be charged the listed mail order Co-payment.
t-) . Your Injectable Medication coverage extends to many injectable medications approved by the FDA. These medications must be prescribed by a physician
lmd dispensed by a retail or specialty pharmacy. The Co-payment levels for Injectable Medications apply regardless of provider. This means Ihal you are
responsible for the appropriate Co-payment whether you receive your Injectable Medication from the phannaey, at the physician's office or during home
health visits. Injectable Medications are limited to a 3D-day supply.
. Your Prescription Dmg coverage includes covemge for injectable contraceptives. There is a Co-payment of $30 for each injection. If there is ,m office visit
associated with the injection, there will be an additional Co-payment required for the office visit.
. Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty org;:mizalions,
anellor evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific quantity limit may apply
for medications that have an increased potential for over-utilization or an increased potential for a Member to experience an adverse effect at higher doses.
QUESTIONS? Call your AvMed Member Services Department at: 1-800-88-AvMed (1-800-882-8633)
EXCLUSIONS ANO LIMITATIONS
. Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative is available, unless otherwise
indicated on AvMed's Fonnulary List.
. Medications not included on AvMed's FOffimlary List.
. Medical supplies, including therapeutic devices, dressings, appliances and support garments
. Replacemenl Prescription Drug products resulting from a lost, slolen, expired, broken or destroyed prescription order or refill
. Diaphragms and other contraceptive devices
. Fertility drugs
. Medications or devices for the diagnosis or treatment of sexual dysfunction
. Dental-specific Medications for dental purposes, including fluoride medications
. Prescription and non-prescription vitamins and minerals except prenatal vitamins
. Nutritional supplements
. Immunizations
. Allergy serums, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients are covered
in accordance wilh the Group Medical and Hospital Service Contract and may be subject to Co-payments or Co-insurance as outlined on the Schedule of
Benefits
. Investigational and experimental drugs (except as required by Florida statute)
. Cosmetic products, including, but not limited to, hair grO\vth, skin bleaching, sun damage and anti-wrinkle medications
. Nicotine suppressants and smoking cessation products and services
. Prescription and non-prescription appetite suppressants and products for the purpose of weight loss
. Compounded prescriptions, except pediatric preparations
. Medications ffild immunizations for non-business related travel, including Tfllilsdennal Scopolamine
Filling (/ prescription at a phan/Jac)';s Ilot a clllimfor benefits alld is llOt subject to the Claims and Appeals procedures IInder ERISA. However. all)' medicines that
require P,10ralltllOrizat;Oll will be treated as a claim for benefits subject to the Claims (Il1d Appears P/Vcedllres. as olltlil/ed ill the Group Medical and Hospital Service
COlltmct.
A V -LG.RX-2x-1 O/20/30n5/50%-09
MP-4000 (10/09)
I)
AvMED
HEALTH PLANS
Addendum
Coverage for Mammograms - Waiver of Co-payment
If selected, the following provision is hereby modified for an additional premium:
Section 10.28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state:
Mammograms are covered in accordance with Florida Statutes: one baseline mammogram is covered for female
Members between the ages of 35 and 39; a mammogram is available every two years for female Members between
the ages of 40 and 49; and a mammogram is available every year for female Members aged 50 and older.
!-)
In addition, one or more mammograms a year are available when based upon a physician's recommendation for any
woman who is at risk for breast cancer because ofa personal or family history of breast cancer, because of having a
history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast
cancer, or because a woman has not given birth before the age of 30. This coverage will not be subject to
diagnostic imaging Co-payments.
A V-Mammogram-05
MP-3228 (12/05)
")
AvMED
Amendment
HEAlTI! PLANS
ELECTIVE TERMINATION OF PREGNANCY
If selected, the following optional coverage is hereby added:
The A vMed Health Plan Group Medical and Hospital Service Contract is amended to state:
. Elective termination of pregnancy will be a covered benefit if the services and treatment are
provided by an AvMed participating provider in an AvMed participating facility. There shall be a
physician copayment of $1 00,00 in addition to the applicable facility copaymenl.
,"
A V-GlOO-ETP-R-97
MP-1321 (1/04)
')
Amendment
AvMED
HEALTH PLANS
Mental Health Services
As of the effective date, outpatient and inpatient mental health services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
. Outpatient mental health services are covered subject to the Member's cost sharing responsibility
for specialist services,
. Inpatient or partial hospitalization for mental health services is covered when a Member is
admitted to a Participating Hospital or Health Care Facility. Coverage is subject to the Member's
cost sharing responsibility for inpatient Hospital Services.
q
Prior authorization is required for mental health services, Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable, For further information,
contact AvMed at 1-800-882-8633.
A V-G toO-MHPH-09
MP-5296 (t 0109)
)
Amendment
AvMED
HEALTH PLANS
Substance Abuse Services
As of the effective date, outpatient and inpatient substance abuse services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
. Outpatient substance abuse services are covered subject to the Member's cost sharing
responsibility for specialist services.
. Inpatient or partial hospitalization for substance abuse services is covered when a Member is
admitted to a Participating Hospital or Health Care Facility. Coverage is subject to the Member's
cost sharing responsibility for inpatient Hospital Services,
q
Prior authorization is required for substance abuse services. Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact A vMed at 1-800-882-8633.
I I
AV-GIOO-SAPH-09
MP-5298 (10109)
')
AvMED
AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application
Contract Number(s):
Subscribing Group Name:
Effective Date:
108498
City of Sunny Isles Beach
03/01/10
Group Contract
q
This Group Contract prl?vides the benefits listed below:
Identifier
AV-OPEN ACCESS-HMO-25/1000/2000-09
AV-Open Acess-09
AV-Deductible/Co-insurance Amendment-09
A V -LG-RX-2x-l 0/20/30/75/50%-OC-B-09
AV-Gl00-MHPH-09
AV-G1 00-SAPH-09
AV-Gl00-ETP-R-97
AV-Mammogram-05
HUALTII PLANS
Descriotion
Summary of Benefits
Open Access
Ded & Co-ins
Prescription Drug
IP Mental Health
Substance Abuse
ETOP
Mammogram
Eliaibilitv
Active Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this Contract.
Employees will become eligible for coverage on the first of the month following the first day of employment.
Management Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this
Contract. Employees will become eligible for coverage on the first of the month following the first day of employment.
Termination
For Active Employees (Class 1), termination of coverage under this Contract shall become effective End of Month.
For Management Employees (Class 1), termination of coverage under this Contract shall become effective End of Month.
Monthlv MembershiD Charaes
Subscriber Only...
Subscriber plus Spouse..
Subscriber plus One Dependent (No Spouse) ...
Subscriber plus Two or More Dependents .....
Subscriber plus Spouse and One or More Dependents ..
AV-Masler Application-O?
MP-202? WOll
$406.37
$902.15
$759.80
$75980
$1,149.79
')
AVMED, INC. d/bla AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
Aareement
This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital
services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED, Inc.
d/b/a AVMED Health Plans and the Subscribing Group. This Contract shall remain in effect for a period of twelve (12)
months from the effective date of March 1, 2010 and may be renewed annually, not later than the anniversary date, upon
mutual agreement of the parties. This Contract period begins at 12:01 a.m. Eastern Standard Time on the effective date or
on the anniversary date, if a renewal. The Contract shall be 90verned by Chapter 641, Florida Statutes, and other applicable
State and Federal laws.
r}
The first monthly payment is due on March 1, 2010. Subsequent payments are due on the 151 day of each month
thereafter.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
The provisions contained in the Schedule of Benefits applicable to this Contract and all Exhibits and Amendments executed
by the parties and attached hereto are, by reference, made a part of this Contract.
AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written.
::"2~'M4
( Sign
Patricia Nelson
Name
Director of Client Services
Date:
02/(fOf7J
AV-Master Application-07
Mp-2027 (1/07)
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY
_~ATTI A~.I)
HANS 0 NOT, CITY AITa EY '"
")
LARGE GROUP
$25/$1,000/$2,000
CALENDAR YEAR
DEDUCTIBLE
OUT-OF-POCKET MAXIMUM
AVMED PRIMARY CARE
PHYSICIAN
H
MATERNITY CARE
AVMED SPECIAlITY HEALTH
CARE PHYSICIAN SERVICES
HOSPITAL
OUTPATIENT SERVICES
OUTPATIENT DIAGNOSTIC
TESTS
Benefit Summary
SCHEDULE OF BENEFITS
INDIVIDUAL! FAMILY
The Deductible does nol apply IowaI'd the Out-oj-Pocket Maximum
INDIVIDUAL! FAMILY per calendar year
The Ou/.ofPockel A1aximuI11 includes Co-payments and Co-
insurance amounts unless oOle/wise excluded
Services at Participating Physicians' offices include, but are not
limited to:
. Routine office visits/annual well-woman examination when
performed by Primary Care Physician
. Pediatric care and well-child care
. Periodic health evaluation and immunizations
. Diagnostic imaging, laboratory or other diagnostic services
. Minor surgical procedures
. Vision and hearing screenings for children under 18
. Initial visit
. Subsequent visits
. Office visits
. Annual well-woman examination when performed by a
participating Specialty Health Care Physician
Additional charges will apply if Outpatient Diagnostic Tests are
performcd in the Specialist's Office.
Inpatient care at Hospitals includes:
. Room and board - unlimited days (semi-private)
. Physicians', specialists' and surgeons' services
. Anesthesia, use of operating and recovery rooms, oxygen, drugs
and medication
. Intensive care unit and other special units, general and special
duty nursing
. Laboratory and diagnostic imaging
. Required special diets
. Radiation and inhalation therapies
. Outpatient surgeries, including cardiac catheterizations and
angioplasty
. Outpatient therapeutic services, including:
. Drug infusion therapy
. Injectable Drugs (Co-payment for Injectable Drug
waived if incidental to same-day drug infusion therapy)
Preventive and diagnostic colonoscopies
. One preventive colonoscopy per lifetime (Not subject to
Calendar Year Deductible)
. CAT Scan, PET Scan, MRI
. Other diagnostic imaging tests
. Mammogram
Charges for office visits will also apply if services are performed in a
Specialist's office,
EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition
requiring immediate medical or surgical care. (Co-payment waived
if admitted)
. Emergency services at Participating Hospitals
. Emergency services at non-participating Hospitals, facilities
and/or physicians
Avl\led must be notified within 24 hours of inpatient admission
following emergency services or as soon as reasonably possible.
A V-LG-25/1000/2000-09
MP-5076 (10/09)
AvMED
HEALTII PLANS
COST TO MEMBER
$1,0001 $2,000 annually
$2,0001 $4,000 annually
$25 per visit; not subject to
Calendar Year Deductible
$25 Co-payment; not subject to
Calendar Year Deductible
NO CHARGE
$50 per visit; not subject to
Calendar Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE
NO CHARGE, after Calendar
Y car Deductible
NO CHARGE; not subject to
Calendar Year Deductible
NO CHARGE, after Calendar
Year Deductible
I')
Benefit Summary, continued
URGENT/lMMEDlATE CARE
$50 Co-payment; not subject to
Calendar Year Deductible
.
FAMILY PLANNING .
.
ALLERGY TREATMENTS .
AMBULANCE
Ie)
PHYSICAL, SPEECH AND .
OCCUPATIONAL THERAPIES
DIAGNOSIS AND TREATMENT
OF AUTISM SPECTRUM
DISORDER
SKILLED NURSING FACILITIES
AND REHABILITATION
CENTERS
CARDIAC REHABILITATION
HOME HEALTH CARE
DURABLE MEDICAL
EQUIPMENT AND
ORTHOTIC APPLIANCES
PROSTHETIC DEVICES
Medical Services at a participating Urgent/Immediate Care
facility or services rendered after hours in your Primary Care
Physician's office
Medical Services at a participating retail clinic
Medical Services at a non-participating Urgent/Immediate Care
facility or non-participating retail clinic
Voluntary family planning services
Sterilization (In addition to any Outpatient Facility charge)
Injections
Skin testing
Ambulance transport for emergency services
Non-emergent ambulance services are covered when the skill of
medically trained personnel is required and the Member cannot
be safely transported by other means
Short-term physical, speech or occupational therapy for acute
conditions
Coverage is limited to 30 visits per calendar year for all services
combined
. Applied Behavior Analysis services
. Physical, speech or occupational therapy for the treatment of
Autism Spectrum Disorder
Coverage for all services related to Autism Spectrum Disorder is
limited to $36,000 annually and may not exceed $200,000 in total
benefits.
. Up to 20 days post-hospitalization care per calendar year when
prescribed by physician and authorized by A vMed
Cardiac rehabilitation is covered for the following conditions:
. Acute myocardial infarction
. Percutaneous transluminal coronary angioplasty (PTCA)
. Repair or replacement of heart valves
. Coronary artery bypass graft (CABG), or
. Heart transplant
Coverage is limited to 18 visits per calendar year
. Limited to 60 skilled visits per calendar year
Equipment includes:
. Hospital beds
Walkers
. Crutches
. Wheelchairs
Orthotic appliances are limited to:
. Leg, arm, back and neck custom-made braces
Prosthetic devices are limited to:
. Artificial limbs
. Artificial joints
. Ocular prostheses
$25 per visit; not subject to
Calendar Year Deductible
$75 Co-payment; not subject to
Calendar Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
$50 per visit; not subject to
Calendar Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
Benefits limited
to $1,500 per
calendar year
NO CHARGE, after Calendar
Year Deductible
NO CHARGE, after Calendar
Year Deductible
Benefits limited
to $2,000 per
calendar year
NO CHARGE, after Calendar
Year Deductible
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-800-88-AVMED (1-800-882-8633)
This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions
and Limitations, please consult your AvMed Group Medical and Hospital Service Contract.
A V-LG-25fIO00/2000-09
MP-5076 (10/09)
'"
Amendment
AvMED
HEALTH PLANS
Large Group. Deductible and Co-insurance
These provisions of the policy are amended as follows:
Parllll. DEFINITIONS, has been amended to add the following definitions:
n
. "Calendar Year" means the twelve-month period beginning January I and ending December 31.
. "Co-insurance" means the amount a covered Member must pay, once the Deductible has been met, and is
expressed as a percentage of the allowed amount for the covered benefit.
. "Deductible" means the first payments up to a specified dollar amount, excluding Co-payments, that a
Member must make in the applicable Calendar Year for covered benefits. The Deductible applies to each
Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the
Deductible, "family" means the Subscriber and Covered Dependents. The Deductible must be satisfied once
each Calendar Year, except for:
o the Common Accident Provision: if the Deductible applies to accident expenses and if 2 or more
Members of any family receive covered benefits because of disabilities resulting from injuries
sustained in anyone accident, the Deductible will be applied only once with respect to all covered
benefits received as a result of the accident.
o the Deductible Credit Provision: any expense incurred by a Member while covered under the
group's prior carrier will be credited toward satisfaction of the Deductible under this Plan if:
o the expenses were incurred during the 90-day period before the effective date of the Group
Plan;
o the expenses were applied toward satisfaction of the Deductible under the prior coverage
during the 90-day period before the effective date of this Group Plan; and
o the expenses would be considered eligible expenses under this Group Plan.
However, in order to receive credit, you must supply evidence of satisfaction of the Deductible
under the prior coverage by providing A vMed Health Plans written proof of what has been paid by
prior carrier.
o the Carryover Provision: if any part or all of the Deductible has been satisfied during the last 3
months of the preceding Calendar Year, the Deductible for the next Calendar year will be reduced
by the amount satisfied.
Under Part VII. MONTHLY PAYMENTS AND CO-PA YMENTS, has been amended as follows:
7.03 Annual Maximum Out-of-Pocket Limits (as described in your Schedule of Benefits). Co-insurance and Co-payments
you pay for benefits received during any Calendar Year are accumulated toward your annual. maximum out-of-pocket
limit. Once you meet your individual or family annual maximum out-of-pocket limit in any Calendar Year, AvMed will
pay 100% of the allowable charges for all covered services for the remainder oftl1at Calendar Year. Expenses that do
not count toward the annual maximum out-of-pocket limit are expenses used to satisfy the individual or family
Deductible and any services provided under the Prescription Drug, Mental Health, Substance Abuse, Vision and other
supplemental riders.
7.04 Member shall pay premiums, applicable supplemental charges, Deductibles, Co-payments and/or Co-insurance as
provided in this Contract. If the Member fails to do so, upon ten (10) days written notice from AvMed to Member, the
Member's rights hereunder shall be terminated. Consideration for reinstatement with AvMed shall require a new
application, and any re-enrollment shall be at the sole discretion of A vMed and shall not be retroactive.
7.07 A Member will be entitled to covered benefits after the Member has satisfied the Deductible amount, ifany, specified on
the Schedule of Benefits. After satistying the Deductible, the Member must pay any applicable Co-insurance for
covered benefits. Covered benefits to which the Deductible applies are shown in the Schedule of Benefits. The
Deductible does not apply to certain covered benefits. In those instances, the Member must pay any applicable Co-
payments for covered benefits to which the Deductible does not apply.
A V-Deductible/Co-insurance Amendment-09
MP-3647 (10/09)
'"l
Amendment
AvMED
HEALTH PLANS
Open Access to Specialty Healthcare Physicians
As of the Effective Date, the introductory language of section X. Schedule of Basic Benefits of the
Group Medical and Hospital Service Contract is amended as follows:
..,
Each Member may select one Primary Care Physician (PCP) upon enrollment, but is not required to
do so. In the event that you do choose a PCP, the Health Plan must be notified and you must receive
approval prior to changing your PCP, Such change will become effective on the first day of the
month after you notify Health Plan, You cannot change your PCP selection more than onCe per
month.
You are entitled to see participating Specialty Health Care Physicians without a referral from your
PCP, Self-referral is not permitted to participating Specialty Health Care Physicians designated as
"Requires Special Consultation between your Doctor and the A vMed Medical Director" in the written
or electronic Provider Directories at the time of service.
Health Professionals may from time to time cease their affiliation with Health Plan, In such cases,
you will be required to receive services from another Participating Health Professional.
A V-Open Access-09
MP-393l (10/09)
)
Prescription Medication Benefits
AvMED"'
HEALTH PLANS
c)
$1 O/20/30nSI50% CO-PAYMENT with Contraceptives
OEFINITIONS
Ul1l1ld medication means a Prescription Drug that is usually manufactured and sold under a name or trJ.demark by a pharmaceutical manufacturer or a
medication that is identified as a Brand medication by AvMed. AvMed delegates detcnnination of GenericlBrand status to our Pharmacy Benefits Manager.
Umud Additional Charge mc<ms the additional charge that must be paid if you choose a Brand medication when a Generic equivalent is available. The
charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to the applicable Non-
Preferred Brand Co-payment. However, if the prescribing physician or other Participating Provider authorized to prescribe medications within the scope of his
or her license indicates on the prescription Brand medically necessary or dispense as written for a medication for which there is a generic equivalent, the Brnnd
medication shall be dispensed for the applicable Non-Preferred Brand Co-payment only.
Cost-sharing i'\iIcdications are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively minor
non-life threatening conditions. Such medications are subject to Co-insunmce and coverage is limited as outlined below.
Dental~spccific Medication is medication used for dental-specific purposes, including but not limited to fluoride medications and medications packaged and
labeled for dental-specific purposes.
Formulary List means the listing of preferred and non-preferred medications as determined by AvMed's Phannacy and Therapeutics Committee based on
clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi-tiered list establishes different levels of
Co-payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been
reviewed by AvMed's Ph:.umacy and Therapeutics Committee.
Generic medication me:.ms a medication that has the same active ingredient a'i a Bnmd medication or is identified as a Generic medication by AvMed's
Phammcy Benefits Manager.
Injectable Medication is a medication that has been approved by the Food and Drug Administration (FDA) for .tdministration by one or more of the
following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection,
intracavernous injection or intraocular injection. Prior authorization is required for all Injectable Medications.
Maintcnancc Medication is a medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed one
year.
Participating Pharmacy means a phmmacy (retail, mail order or specialty ph,mnacy) that has entered into an agreement with AvMed to provide Prescription
Drugs to AvMed Members and has been designated by AvMed as a Pm1icipating Pharmacy.
Prescription Drug means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and
fedcrJ,llaw.
Plior Authori7.ation means the process of obtaining approval for certain Prescription Dmgs (prior to dispensing) according to AvMed's guidelines. The
prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Prior Authorization is subject to periodic review and
modification by AvMed. A copy of the list of medications requiring Prior Authorization and the applicable criteria are available from Member Services or from
the AvMed website.
HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK?
To obtain your Prescription Dmg, take your prescription to, or have your physician call, an AvMed Participating Phannacy. Your physician should submit
prescriptions for Injectable Medications to AvMed's specialty pharmacy. Present your prescription along with your AvMed identification card. Pay the
following Co-payment (as well as the Brand Additional Charge if you choose a Brand product when a Generic equivalent is available).
) lier I Preferred Generic Medications: $ 10.00 Co-payment
lier2 Preferred Brand Medications: $ 20,00 Co-payment
Tier 3 Non-Preferred Brand or Generic Medications: $ 30,00 Co-payment
Tier 4 Injectable Medications: $ 75.00 Co-payment
Tier 5 Cost-sharing Medications: 50% Co-Insurance
ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL
Mail service is a benefit option for maintenance medications needed for chronic or long-tenn health conditions. It is best to get an initial prescription filled at
your retail phannacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Up to
3 refills are allowed per prescription. Pay the following Co-payment (as well as the Brand Additional Charge if you choose a Bnmd product when a Generic
equivalent is available).
Tier 1
Tier 2
Tier 3
Tier 4
TierS
$
$
Non-Preferred Brand or Generic Medications: $
Injectable Medications are not available through mail service
Cost-sharing Medications are not available through mail service
20.00
40.00
60,00
Co-payment
Co-payment
Co-payment
Preferred Generic Medications:
Preferred Brdlld Medications:
A V -LG-RX.2x-l 0I20/30nS/SO%.B-09
Mp.4000 (10/09)
r")
Prescription Medication Benefits, continued
WHAT IS COVERED?
. Your Prescription Drug coverage includes outpatient mediC<ltions (including contraceptives) that require a prescription and are prescribed by your AvMcd
physician in accordance with AvMcd's covcrnge criteria. AvMed reserves the right to make changes in coverage criteria for covered products and services.
Coverage criteria are medical and pharmaceutical protocols used to dctcnninc payment of products and services and are based on independent clinical
prnctice guidelines and sl<Uldarus of care established by government agencies and mcdicaVpharmaceutical societies.
. Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Program. for cCltmn covered medications. The
Progressive Medication Program encourages the use of therapeutically-equivalent lower-cost medications by requiring cel1ain medications to be utilized to
treat a medical condition prior to approving another medication for that condition. This includes the first-line use of preferred medications that are proven to
be safe and effective for a given condition and can provide the same health benefit as more expensive non-preferred medications at a lower cost.
Your retail Prescription Drug coverage includes up to a 3D-day supply of a medication for the listed Co-payment. Your prescription may be refilled via
retail or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have the opportunity to obtain a
90-day supply of medications used for chronic conditions including, but not limited to asthma, cardiova'icular disease, and diabetes from the retail
pharmacy for the applicable Co-pa)1ncnt per 3D-day supply. However, Prior Authorization may be required for covered medications.
. Your mail-order Prescription DlUg coverage includes up to a 90-day supply of a routine maintenance medication for the listed Co-payment. If the amount
~ ) of medication is less than a 90-day supply, YOll will still be charged the listed mail order Co-payment.
. Your Injectable Medication coverage extends to many injectable medications approved by the FDA. 1l1ese medications must be prescribed by a physician
and dispensed by a retail or specialty phrumacy. The Co-pa)1nent levels for Injectable Medications apply regardless of provider. This means that you are
responsible for the appropriate Co-pa)1nent whether you receive your Injectable Medication from the pharmacy, at the physician's office or during home
health visits. Injectable Medications are limited to a 3D-day supply.
. Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co-pa)1nent of $30 for each injection. If there is an office visit
associated with the injection, there will be;m additional Co-pa)1nent required for the office visit.
. Qmmtity limits arc set in accordance with fDA approved prescribing limitations, general practice guidelines supported by medical specially organizations,
and/or evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific qU<U1tity limit may npply
for mcdicntions that have an increased potential for over-utilization or an increased potential for a Member to experience an adverse effect at higher doses.
QUESTIONS? Call your AvMed Member Services Department at: 1-800-88-AvMed (1-800-882.8633)
EXCLUSIONS AND LIMITATIONS
. Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription altemative is available, unless otherwise
indicated on AvMed's Fonnulary List.
. Medications not included on AvMed's Fonnulary List.
. Medical supplies, including therapeutic devices, dressings, appliances and support gm111ents
. Replacement Prescription Drug products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill
. Diaphragms and other contraceptive devices
. Fertility drugs
. Medications or devices for the dingnosis or treatment of sexual dysfunction
. Dental-specific Medications for dental purposes, including fluoride medications
. Prescription and non-prescription vitamins and minerals except prenntal vitamins
. Nutritional supplements
. Immunizations
. Allergy serums, medications ndministercd by the Attending Physici,mto treat the acute phase of an illness and chemotherapy for cancer patients are covered
in accordance with the Group Medical and Hospital Service Contract and may be subject to Co-payments or Co-insurance as outlined on the Schedule of
Benefits
. Investigational and experimental drugs (except as required by Rorida statute)
. Cosmetic products, including. but not limited to, hair gro\Vth, skin bleaching. sun damage and anti-wrinkle medications
. Nicotine suppressants and smoking cessation products <md services
. Prescription and non-prescription appetite suppressants and products for the purpose of weight loss
. Compounded prescriptions, except pediatric preparations
. Medications and immunizations for non-business related travel, including Transdennal Scopolamine
Filling a prescription at a phanllac)' is /lOt a claim for benefits (lnd is not subject to the Claims and Appeals procedures flllder ERISA. Howel'er, an)' medicines that
require Prior authorization will be treated as a claim for belle fits subject to the Claims ami Appeals Procedures, as ol/tlined ill the Group Medical alld Hospital Serdce
Contract.
A V -LG-RX-2x. J OnO/30n 5/50%-09
MP-4000 (10/09)
'1
AvMED
HEALTH PLANS
Addendum
Coverage for Mammograms - Waiver of Co-payment
If selected, the following provision is hereby modified for an additional premium:
Section 10.28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state:
Mammograms are covered in accordance with Florida Statutes: one baseline mammogram is covered for female
Members between the ages of 35 and 39; a mammogram is available every two years for female Members between
the ages of 40 and 49; and a mammogram is available every year for female Members aged 50 and older.
t)
In addition, one or more mammograms a year are available when based upon a physician's recommendation for any
woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a
history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast
cancer, or because a woman has not given birth before the age of 30. This coverage will not be subject to
diagnostic imaging Co-payments.
A V -Mammogram-05
MP-3228 (12/05)
')
AvMED
HEAlTII PLANS
Amendment
ELECTIVE TERMINATION OF PREGNANCY
Ifselected, the following optional coverage is hereby added:
The A vMed Health Plan Group Medical and Hospital Service Contract is amended to state:
. Elective termination of pregnancy will be a covered benefit if the services and treatment are
provided by an A vMed participating provider in an A vMed participating facility, There shall be a
physician co payment of$IOO.OO in addition to the applicable facility copaymenl.
I'}
AV-GIOO-ETP-R.97
MP-1321 (1104)
')
Amendment
AvMED
HEALTH PLANS
Mental Health Services
As of the effeclive date, outpatient and inpatient mental health services are covered, when Medically
Necessary, subject 10 the following Member cost sharing responsibility:
. Outpatient mental health services are covered subject to the Member's cosl sharing responsibility
for specialist services,
. Inpatient or partial hospitalization for mental health services is covered when a Member is
admitted to a Participating Hospital or Health Care Facility. Coverage is subject to the Member's
cost sharing responsibility for inpatient Hospital Services.
q
Prior aulhorization is required for mental health services. Please consult the Schedule of Benefils for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact AvMed at 1-800-882-8633.
A V-G 100-MHPH-09
MP-5296 (10109)
f)
I
Amendment
AvMED
HEALTH PLANS
Substance Abuse Services
As of the effective date, outpatient and inpatient substance abuse services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
. Outpatient substance abuse services are covered subject 10 the Member's cost sharing
responsibility for specialist services.
. Inpatient or partial hospitalization for substance abuse services is covered when a Member is
admitted to a Participating Hospital or Health Care Facility. Coverage is subject to the Member's
cost sharing responsibility for inpatient Hospital Services,
)
Prior authorization is required for substance abuse services. Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact AvMed at 1-800-882-8633.
A V-G 100-SAPH-09
MP-5298 (10109)
()
)
()
A V-CHOICE-2009
MP-5320 (10/09)
AvMed Health Plans
AvMed Choice
Group
Medical and Hospital Service Contract
with
I'oint of Service Ridel'
,
TABLE OF CONTENTS
)
SERVICE AREAS ................................................................................................................................................. i
I. GENERAL .................................................................................................................................................. I
II. DEFINITIONS ........................................................................................................................................... 2
III. ELIGIBILITY ............................................................................................................................................ 8
IV. ENROLLMENT ....................................................................................................................................... 10
V. EFFECTIVE DATE OF MEMBERSHIP..............................................................................................12
VI. MONTIIL Y PAYMENTS AND CO-PAYMENTS ............................................................................... 13
~\
VII. CONVERSION ......................................................................................................................................... 14
VIII. TERMINA nON ...................................................................................................................................... 15
IX. SCHEDULE OF BASIC BENEFITS...................................................................................................... 21
X. LIMITATIONS OF BASIC BENEFITS ................................................................................................ 31
XI. EXCLUSIONS FROM BASIC BENEFITS ........................................................................................... 32
XII. COORDINATION OF BENEFITS ........................................................................................................ 37
XIII. SUBROGATION AND RIGHT OF RECOVERy................................................................................ 39
)
XIV. DISCLAIMER OF LIABILITY ............................................................................................................. 41
XV. GRIEVANCE PROCEDURE ....;............................................................................................................ 41
XVI. MISCELLAN EO US ................................................................................................................................. 47
A V-CHOICE-2009
MP-5320 (10/09)
I")
)
AVMED CORPORATE OFFICE
9400 S. DADELAND BLVD.
MIAMI, FL 33156-9004
AVMED MEMBER SERVICES -ALLAREAS
1-800-88 A VMED
(1-800-882-8633)
ICI
MIAMI
9400 South Dadeland Boulevard
Miami, Florida 33156-9004
(305) 671-5437
(800) 432-6676
Miami-Dade
)
FT. LAUDERDALE
13450 W. Sumise Boulevard
Suite 370
Sunrise, Florida 33323-2947
(954) 462-2520
(800) 368-9189
Broward
Palm Beach
ORLANDO
1800 Pembroke Drive
Suite 190
Orlaudo, Florida 32810
(407) 539-0007
(800) 227-4848
Lake'
Orange
Osceola
Seminole
SERVICE AREAS
GAINESVILLE
4300 N.W. 89"' Boulevard
Post Office Box 749
Gaiuesville, Florida 32606-0749
(352) 372-8400
(800) 346-0231
Alachua
Bradford
Citrus
Columbia
Dixie
Gilchrist
Hamilton
Levy
Marion
Suwannee
Union
JACKSONVILLE
1300 Riverplace Boulevard
Suite 640
Jacksonville, Florida 32207
(904) 858-1300
(800) 227-4184
Baker
Clay
Duval
Nassau
St. Johns
TAMPA BAY! SOUTHWEST
FLORIDA
1511 North Westshore Boulevard
Suite 450
Tampa, Florida 33607
(813) 281-5650
(800) 257-2273
Hernando
Hillsboro
Lee
Pasco
Pinellas
Polk
Sarasota
, Coverage available in the following Lake County zip codes: 34736, 34711, 34712, 34713, 34714, 34715 and
34756
A V-CHOICE-2009
MP-5320 (10/09)
)
AvMed, Inc.
d/b/a AvMed HEALTH PLANS
)
GROUPMEDlCAL AND HOSPITAL SERVICE CONTRACT
WITH
POINT OF SERVICE RIDER
IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein and of
mutual promises and benefits hereinafter described, AvMed, Inc., a Florida corporation, d/b/a AvMed Health
Plans, (hereinafter referred to as 'AvMed'), and (hereinafter referred to as 'Subscribing Group') agree as
follows:
I. GENERAL
The Subscribing Group engages AvMed to arrange for the provision of Medical Services or benefits which are
Medically Necessary for the diagnosis and treatment of Members of the Subscribing Group through the AvMed
Choice Plan. The AvMed Choice Plan provides the Member with several choices for the provision of health
care services: the A vMed Choice Network, the Private Healthcare Systems Network (PHCS) or out-of-network
coverage. The Member's choice of providers and where they receive services will detem1ine the level of
benefits. Under this Plan, a Member may choose to receive services from the AvMed Choice Network (high
Benefit Lcvel), the PHCS Network (medium Bcnefit Level) or any Out-of-Network Provider (low Benefit
Level). With the AvMed Choice Plan, a Member is not required to select a Primary Care Physician nor are
referrals to specialists required. However, prior authorization from AvMed is required for some services (See
Section IX). AvMed, in arranging for the delivery of Medical Services or benefits, does not directly provide
these Medical Services or benefits. AvMed arranges for the provision of said services in accordance with the
covenants and conditions contained in this Contract. AvMed shall rely upon the statements of the Subscriber in
his application in providing coverage and benefits hereunder.
This Contract is not intended to and does not cover or provide any Medical Services or benefits that are not
Medically Necessary for the diagnosis and treatment of the Member. The determination as to which services are
Medically Necessary shall be made by AvMed subject to the terms and conditions of this Contract.
AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage
criteria are medical and pharmaceutical protocols used to detenninc payment of products and services and are
based on independent clinical practice guidelines and standards of care established by government agencies and
medicaVpharmaceutical societies.
The Medical and Hospital Services covered by this Contract shall be provided without regard to the race, color,
religion, physical handicap, or national origin of the Member in the diagnosis and treatment of patients; in the
use of equipment and other facilities; or in the assignment of personnel to provide services, pursuant to the
provisions of Title VI of the Civil Rights Act of 1964, as amended, and the Americans with Disabilities Act of
1990.
,)
)
A V-CHOICE-2009
MP-5320 (10/09)
')
)
II. DEFINITIONS
As used in this Contract, each of the following terms shall have the meaning indicated:
2.01 Accidental Dental Injury means an injury to sound natural teeth caused by a sudden, unintentional,
and unexpected event or force. This term does not include injuries to the mouth, structures within the
oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a disease or
illness.
2.02
Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for, a benefit, including any such denial, reduction, tennination, or
failure to provide or make payment that is based on a determination of a Member's eligibility to
participate in the Plan, and including a denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for, a benefit resulting from the application of any Utilization
Management Program, as well as a failure to cover an item or service for which benefits arc otherwise
provided because it is determined to be experimental and/or investigational or not Medically Necessary.
2.03 Applied Behavior Analysis means the design, implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences, to produce socially significant improvement
in human behavior, including, but not limited to, the use of direct observation, measurement, and
functional analysis of the rclations betwecn environment and behavior. Applied behavior analysis
services shall be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an
individual licensed under Chapter 490 or Chapter 491, Florida Statutes.
n
2.04 Attending Physician means the physician primarily responsible for the care of a Member with respect
to any particular injury or illness.
2.05
Autism Spectrum Disorder means any of the following disorders as defined in the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:
\
/
2.05.01
2.05.02
2.05.03
Autistic disorder;
Asperger's syndrome;
Pervasive developmental disorder not otherwise specified.
2.03 AvMed Choice Network means the providers and facilities that have contracted with AvMed to
provide covered services to our Subscribers and Dependents. The Members' Co-payment, Deductible
and Co-insurance responsibilities are outlined in the Schedule of Benefits. Generally, Members will
have coverage at the highest level of benefits when they use the AvMed Choice Network.
2.06 AvMcd, Inc. otherwise known as 'AvMed', means a private not for profit Florida corporation, state
licensed as a health maintenance organization under Chapter 641, Florida Statutes, for the pnrpose of
arranging for prepaid health care services to its Members under the tenns and conditions set forth in this
Contract.
2.07 Benefit Level means:
2.07.01
Fur AvMed Choice providers and PHCS providers, the Co-payment or percentage of the
contracted rate shown in the Schedule of Benefits after the applicable Deductible is met; or
For Non-participating Providers, the Maximum Allowable Payment for covered services
shown in the Schedule of Benefits after the applicable Deductible.
The Deductible may not apply to all covered services. See Schedule of Benefits.
2.07.02
2.07.03
2.08 Claim means a request for benefits under this Contract made by a Member in accordance with AvMed's
procedures for filing benefit claims, including Pre-Service Claims and Post-Service Claims.
2
A V-CHOtCE-2009
MP-5320 (10/09)
)
2.09 Claimant means a Member or a Member's authorized representative acting on behalf of the Member.
AvMed may establish procedures for determining whether an individual is authorized to act on behalf of
the Member. If the Claim is an Urgent Care or Pre-Service Claim, a Health Professional, with
knowledge of the Member's medical condition, shall be permitted to act as the Member's authorized
representative and will be notified of all approvals on the Claimant's behalf. In the event of an Adverse
Benefit Determination, AvMed will notifY both the Member and the Heath Professional.
2.10 Co-insurance means the amount a covered Member must pay, once the Deductible has been met if
applicable, and is expressed as a percentage of the contracted rate for the covered benefit.
2.11 Concurrent Care means an ongoing course of treatment to be provided over a period of time or number
of treatments that was previously approved by AvMed.
)
Contract means this Group Medical and Hospital Service Contract with Point of Service Rider which
may at times be referred to as 'Group Contract' or 'Point of Service Plan' and all applications, rate
letters, face sheets, riders, amendments, addenda, exhibits, supplemental agreements, and schedules
which are or may be incorporated in this Contract from time to time.
2.13 Contract Year means the period of consecutive months agreed to by the Subscribing Group and AvMed
on the Master Application, cOITunencing on the effective date of this Contract.
2.12
.j
2.14 Conversion Contract means an individual Member or Subscriber contract which shall be available to
continue coverage (as provided for therein) of the Subscriber or the Dependent of the Subscriber upon
termination of the Subscribing Group Contract as provided in Part VII of this Contract, and shall at
times be referred to as the 'Individual Conversion Contract.'
2.15
Co-payment means the portion of the amount requested, in addition to the amount of the prepaid
premiums, which the SubscriberlMember is required to pay at the time certain health services are
provided nnder this Contract. The Co-payment may be a specific dollar amount or a percentage of the
cost. The Member is responsible for the payment of any Co-payment amounts directly to the provider of
the health services at the time of service.
)
2.16 Custodial Care means services and supplies that are furnished mainly to train or assist in the activities
of daily living, such as bathing, feeding, dressing, walking, and taking oral medications. 'Custodial
Care' also means services and supplies that can be safely and adequately provided by persons other than
licensed health professionals, such as dressing changes and catheter care, or that ambulatory patients
customarily provide for themselves, such as ostomy care, administering insulin, and measuring and
recording urine and blood sugar levels.
2. I 7 Dental Care means dental x-rays, examinations and treatment of'the teeth or any services, supplies or
charges directly related to:
The care, filling, removal or replacement of teeth; or
The treatment of injuries to or disease of the teeth, gums or structures directly supporting or
attached to the teeth, that are customarily provided by dentists (including orthodontics
reconstructive jaw surgery, casts, splints, and services for dental malocclusion).
2.18 Dependent means any member ofa Subscriber's family who meets all applicable requirements of Part
III and is enrolled hereunder and for whom the prepayment required by Part VI has actually been
received by Av Med
2.17.01
2.17.02
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2.19.01
Emergency Medical Condition means:
2.19
2.19.02
o
A medical condition manifesting itself by acute symptoms of sufficient severity such that the
absence of immediate medical attention could reasonably be expected to result in any of the
following:
a) Serious jeopardy to the health of a patient, including a pregnant woman or fetus.
b) Serious impairment to bodily functions.
c) Serious dysfunction of any bodily organ or part.
With respect to a pregnant woman:
a) That there is inadequate time to effect safe transfer to another Hospital prior to delivery;
b) That a transfer may pose a threat to the health and safety of the patient or fetus; or
c) That there is evidence of the onset and persistence of uterine contractions or rupture of
the membranes.
Examples of Emergency Medical Conditions include, but are not limited to: heart attack,
stroke, massive internal or external bleeding, fractured limbs, or severe trauma.
2.20 Emergency Medical Services and Care means medical screening, examination, and evaluation by a
physician, or, to the extent permitted by applicable law, by other appropriate personnel under the
supervision of a physician, to determine if an Emergency Medical Condition exists and, if it does, the
care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the
Emergency Medical Condition within the service capability of the Hospital.
In-area emergency does not include elective or routine care, care of minor illness, or care
that can reasonably be sought and obtained from the Member's physician. The detemlination
as to whether or not an illness or injury constitutes an emergency shall be made by AvMed
and may be made retrospectively based upon all information known at the time the patient
was present for treatment.
Out-of-area emergency does not include care for conditions for which a Member could
reasonably have foreseen the need of such care before leaving the Service Area or care that
could safely be delayed until prompt return to the Service Area. The determination as to
whether or not an illness or injury constitutes an emergency shall be made by AvMed and
may be made retrospectively based upon all infornmtion known at the time the patient was
present for treatment.
2.21 Exclusion means any provision of this Contract whereby coverage for a specific hazard or condition is
entirely eliminated.
2.19.03
2.20.01
)
2.20.02
2.22 Full-Time Student or Part-Time Student means one who is attending a recognized and/or accredited
college, university, vocational, or secondary school and is carrying sufficient credits to qualify as a Full-
Time or Part-Time Student in accordance with the requirements of the school. See Snbsection
3.02.02(1).
2.23 Group nealth Insurance (for purposes of Part XII) means that fonn of health insurance covering
groups of persons under a master Group Health Insurance policy issued to anyone of the groups listed
in Sections 627.552 (employee groups), 627.553 (debtor groups), 627.554 (labor union and association
groups), and 627.5565 (additional groups), Florida Statutes.
2.23.01
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The terms 'amount of insurance' and linsurance' include the benefits provided under a plan
of self-insurance.
4
2.23.02
The term 'insurer' includes any person, entity, or governmental unit providing a plan of self-
insurance.
)
The terms 'policy', 'insurance policy', 'health insurance policy', and 'Group Health
Insurance policy' include plans of self-insurance providing health insurance benefits.
2.24 Health Professionals means physicians, osteopaths, podiatrists, chiropractors, physician assistants,
nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists, occupational
therapists, physical therapists, and other professionals engaged in the delivery of health care services
who are licensed and practice under an institutional license, individual practice association, or other
authority consistent with State law.
2.23.03
2.25 Home Health Care Services (Skilled Home Health Care) means services that are provided for a
Member who does not require conlinement in a Hospital or Other Health Care Facility. Such services
include, but are not limited to, the services of professional visiting nurses or other health care personnel
for services covered under this Contract. A visit is limited to a period of2 hours or less.
2.26 Hospice means a public agency or private organization that is duly licensed by the State to provide
Hospice services. Such licensed cntity must be principally engaged in providing pain relief, symptom
management, and supportive services to terminally ill Members.
2.27 Hospital means any general acute care facility which is licensed by the State.
2.28 Hospital Based Providers are defined as emergency room physicians, pathologists, radiologists and
anesthesiologists.
2.29 Hospital Services (except as expressly limited or excluded by this Contract) means those services for
registered bed patients that are:
Generally and customarily provided by acute care general Hospitals in accordance with the
standards of acceptable community practice;
Performed, prescribed, or directed by an Attending Physician; and
Medically Necessary for conditions which cannot be adequately treated in Other Health Care
Facilities or with Home Health Care Services or on an ambulatory basis.
2.30 Hospitalist/Admitting llanclist means a physician who specializes in treating inpatients and who may
coordinate a Member's health care when the Member has been admitted for a Medically Necessary
procedure or treatment at a Hospital.
2.29.01
2.29.02
2.29.03
)
2.31 Injectable Medication means a medication that has been approved by the Food and Drug
Administration (FDA) for administration by one or more of the following routes: intramuscular
injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection,
intrarticular injection, intracavernous injection or intraocular injection. Pre-authorization is required for
Injectable Medications.
2.32 Limitation means any provision (other than Exclusions) which restricts coverage under this Contract.
2.33 . Master Application means the Subscribing Group application form entitled 'Master Application' which
becomes a part of the Contract when the Master Application has been completed and executed by the
Subscribing Group and AvMed.
2.34 Maximum Allowable Payment means the maximum amount that AvMed will pay for any covered
service rendered by a Non-participating Provider or supplier of services, medications, or supplies. The
maximum amount that AvMed will pay for each such covered service can be found on the Maximum
Allowable Payment Schedule available at www.avmed.org .
2.35 Medical Office means a physician's office.
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2.36 Medical Services (except as limited or excluded by this Contract) means those professional services of
physicians and other Health Professionals, including medical, surgical, diagnostic, therapeutic, and
preventive services that are Medically Necessary (except for preventive services as stated herein) for the
diagnosis and treatment of injury or illness.
2.37 Medically Necessary means the use of any appropriate medical treatment, service, equipment, and/or
supply as provided by a Hospital, skilled nursing facility, physician, or other provider which is
necessary for the diagnosis, care, and/or treatment of a Member's illness or injury, and which is:
Consistent with the symptom, diagnosis, and treatment of the Member's condition;
The most appropriate level of supply and/or service for the diagnosis and treatment of the
Member's condition;
In accordance with standards of acceptable community practice;
Not primarily intended for the personal comfort or convenience of the Member, the
Member's family, the physician, or other health care providers;
Approved by the appropriate medical body or health care specialty involved as effective,
appropriate, and essential for the care and treatment of the Member's condition; and
Not experimental or investigational.
2.37.01
2.37.02
2.37.03
0 2.37.04
2.37.05
)
2.37.06
2.38 Member means any Subscriber or Dependent, as described in Sections 2.53 and 2.18, of this Contract.
2.39 Non-notification Penalty means a defined dollar anlount, as specified in the Schedule of Benefits that
may be assessed for failure to obtain prior authorization for certain medical services or medications as
defined in Section 2.59, Utilization Management Program, and under 'Prior authorization for covered
services' found in the introduction to Part IX, Schednle of Basic Benefits. The penalty does not count
towards any deductible or out-of-pocket maximum.
2.40 Non-participating Provider means any Health Professional (or group of Health Professionals),
Hospital, Medical Office, or Other Health Care Facility with whom AvMed has neither made
arrangements nor contracted to render the professional health services set forth herein as a Participating
Provider. The Point of Service Plan provides access to Non-participating Providers as defined herein
including providers and facilities under contract by the PHCS Network outside of AvMed's Service
Area.
2.41 Other Health Care Facility(ies) means any licenscd facility, other than acutc care Hospitals and those
facilities providing services to ventilator dependent patients, which provides inpatient services such as
skilled nursing care and rehabilitative services.
2.42 Ont-of.Network Provider means any Health Professional (or group of Health Professionals), Hospital,
Medical Office, or Other Health Care Facility who is not under contract with AvMed's Choice Network,
and not under contract with the PHCS Network outside of the Service Area.
2.43 Participating Provider means any Health Professional (or group of Health Professionals), Hospital,
Medical Office, or Other Health Care Facility within the AvMed Choice Network with whom AvMed
has made arrangements or contracted to render the professional health services set fonh herein.
2.44 Participating Physician means any Participating Provider licensed under Chapter 458 (physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes.
2.45 Post-Service Claim means any Claim for benefits under the Plan that is not a Pre-Service Claim.
2.46 Pre-Service Claim means any Claim for benefits under the Plan with which (in whole or in part) a
Member must obtain authorization from AvMed in advance of such services being provided to or
received by the Member.
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Primary Care Physician means any Participating Physician licensed under Chapter 458 (physician) or
459 (osteopath), Florida Statutes, who is engaged in family practice, pediatrics, internal medicine,
obstetrics/gynecology, or any specialty physician from time to time designated by AvMed as a 'Primary
Care Physician' in AvMed's current list of physicians and Hospitals.
2.48 Private Duty Nursing means services provided by registered nurses, licensed practical nurses, or any
other trained attendant whose services ordinarily are rendered to, and restricted ta, a particular Member
by arrangements between the Member and the private-duty nurse or attendant. Such persons are
engaged or paid by an individual Member or by someone acting on their behalf, including a hospital that
initially incurs the costs and looks to the Member for reimbursement for such services.
2.47
')
2.49 Private Healthcare Systems (PIICS) means a proprietary Preferred Provider Organization with whom
A vMed has entered into an agreement to provide Medical Services outside A vMed's Service Area. The
Point of Service Plan provides access to the PHCS provider network as defined herein. Members' Co-
payment, deductible and Co-insurance responsibilities are outlined in the Schedule of Benefits.
Relevant Document means any documentation that:
2.50
c~)
2.50.01
Was relied upon in making a benefit detennination;
Was submitted, considered or generated in the course of making a benefit determination,
without regard to whether it was relied upon in making the detennination;
Demonstrates compliance with the Plan's administrative process; and
Constitutes a statement of policy or guidance with respect to the Plan concerning the
Adverse Benefit Determination for the Claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the Adverse Benefit Detennination.
Self-Administered Injectable Medication means a medication that has been approved by the FDA for
self-injection and is administered by subcutaneous injection or a medication for which there are
instructions to the patient for self-injection in the manufacturer's prescribing infonnation (package
insert).
)
2.50.02
2.50.03
2.50.04
2.51
2.52 Service Area means those counties in the State of Florida where AvMed has been approved to conduct
business by the Agency for Health Care Administration (AHCA).
2.53 Sound Natural Tooth means a tooth that is whole or properly restored (restoration with amalgams
only) and is not in need of the treatment provided for any reason other than an accidental injury. For
purposes of this Plan, a tooth previously restored with a crown inlay, oolay, or porcelain restoration, or
treated by endodontics, is not considered a sound natural tooth.
2.54 Specialty Health Care Physician means any physician licensed under Chapters 458 (physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, other than the Member's chosen
Primary Care Physician.
2.55 Subscriber means a person who meets all applicable requirements of Section 3.01, enroIls in the Plan,
and for whom the premium prepayment required by Part VI has actually been received by AvMed.
2.56 Subscribing Group means a corporation, partnership, limited liability company or other legal entity
(and its wholly-owned subsidiaries) that negotiates and agrees to contract for the health services and
benefits provided herein for its eligible employees.
2.57 Total Disability means a totally disabling condition resulting from an illness or injury which prevents
the Member from engaging in any employment or occupation for which he may otherwise become
qualified by reason of education, training, or experience, and for which the Member is under the regular
care of a physician.
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2.58
Urgent Care Claim means any Claim for medical care or treatment that could seriously jeopardize the
Member's life or health or the Member's ability to regain maximum function or, in the opinion of a
physician with knowledge of the Member's medical condition, would subject the Member to severe pain
that cannot be adequately managed without the care or treatment requested. Generally, the
detennination of whether a Claim is an Urgent Care Claim shall be made by an individual acting on
behalf of AvMed applying the judgment of a prudent layperson who possesses an average knowledge of
health and medicine. However, if a physician with knowledge of the Member's medical condition
determines that the Claim is an Urgent Care Claim, it shall be deemed as such.
2.59 Urgent Carc/Immcdiate Care means medical screening, examination, and evaluation received in an
Urgent Care Center or Immediate Care Center or rendered in your Primary Care Physician's office after-
hours and the covered services for those conditions which, although not life-threatening, could result in
serious injury or disability ifleft untreated.
,)
2.60
Utilization Management Program means those comprehensive initiatives that are designed to validate
medical appropriateness and to coordinate covered services and supplies. These include, but are not
limited to:
)
Concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and
skilled nursing facilities, including on-site review when appropriate;
Case management and discharge planning for all inpatients and those requiring continued
care in an alternative setting (such as home care or a skilled nursing facility) and for
outpatients when deemed appropriate; and
The Benefit Coordination Program which is designed to conduct prospective reviews for
select medical services to ensure that services are covered and Medically Necessary. The
Benefit Coordination Program may also advocate alternative cost-effective settings for the
delivery of prescribed care and may identify other options for non-covered health care needs.
2.61 Ventilator Dependent Care Unit means care received in any facility which provides services to
ventilator dependent patients other than acute Hospital care, including all types of facilities known as
sub-acute care units, ventilator dependent units, alternative care units, sub-acute care centers, and all
other like facilities whether maintained in a free standing facility or maintained in a Hospital or skilled
nursing facility setting.
2.60.02
2.60.01
2.60.03
III. ELIGIBILITY
3.01 To be eligible to el110ll as a Subscriber, a person must be:
3.01.01 An employee of the Subscribing Group who works the required number of hours per week as
set forth in the Master Application for this Contract;
3.01.02 Employed for the period of time required for eligibility as set forth in the Master
Application; and
3.01.03 Entitled on his own behalf to participate in the mcdical and Hospital care benefits arranged
by the Subscribing Group under this Contract.
3.02 To be eligible to enroll as a Dependent, a person must be,
3.02.01 The spouse of the Subscriber (a new sponse must be el110lled within 31 days after marriage
in order to be covered); or
3.02.02
A child of the Subscriber, or a child of a covered Dependent of the Subscriber, provided that
all of the following conditions apply:
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3.02.03
3.02.04
3.02.05
3.02.06
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)
a) The child is the natural child or stepchild of the Subscriber; a legally adopted child in
the custody of the Subscriber from the time ofplacemcnt in the home (written evidence
of adoption must be l'nmished to AvMed upon request); a child for whom the Subscriber
has been appointed legal guardian, pursuant to a valid court order; or a newborn child
ofa covered Dcpendent of the Subscriber (such coverage terminates 18 months after the
birth of the newborn child);
b) The child resides with the Subscriber (except for 'e' and 'g' below);
c) The child is under the age of 19 (except for 'e' and 'f below, or Section 3.04 below);
d) The child is principally dependent upon the Subscriber for maintenance and support and
is not regularly employed by one or more employers for a total of 30 hours or more per
week;
)
e) The child, from age 19 through the end of the calendar year when the child turns 25, if
the child meets the following requirements:
I) The child is dependent upon the Subscriber for support; and
2) The child is living in the household of the Subscriber or the child is a Full-Time or
Part-Time Student. See Section 2.22.
f) The child is age 19 or over and is wholly dependent on the Subscriber due to mental
retardation or physical handicap. See Section 3.05.
g) It is the Subscriber's responsibility to notify AvMed when the child no longer meets
these requirements. Termination of coverage may be retroactively applied if AvMed is
not notified within 31 days. Subscriber agrees to provide supporting documentation
upon request by AvMed.
In the event that the enrolled Dependent child, who is a Full-Time or Part-time Student,
suffers from a serious illness or injury requiring a leave of absence from school which would
otherwise cause the Dependent child to lose eligibility under the plan, coverage will be
extended for one year from the first day of the leave of absence or the date on which
coverage under the plan would otherwise terminate, whichever occurs first. AvMed will
require written certification from a treating physician stating the Dependent is suffering from
a serious illness or injury and that the leave of absence is Medically Necessary.
lu the cvent an eligible Dependent child does not reside with the Subscriber, coverage will
be extended when the Subscriber is obligated to provide medical care by a Qualified Medical
Child Support Order. You (or your beneficiaries) may obtain, without charge, copies of the
Plan's procedures governing Qualified Medical Child Support Orders and a sample Qualified
Medical Child Support Order by contacting the Plan Administrator.
In the case of a newborn child, AvMed should be notified in writing prior to the scheduled
delivery date of the Subscriber's intention to enroll the newborn child, but such notice shall
not be later than 31 days after the birth. If timely notice is provided, no additional preminm
will be charged for the additional coverage of the newbom during the 31-day period
following the birth of the child. If timely notice is not provided, the additional premium for
the additional coverage of the newborn child will be charged from the child's date of birth.
If notice is not provided within 60 days of the birth, the child may not be el110lled until the
next open enrollment period of the Snbscribing Group.
All services applicable for covered Dependent children under this Contract shall be provided
to an enrolled newborn child of the Subscriber or to the enrolled newborn child of a covered
Dependent of the Subscriber or to the newborn adopted child of the Subscriber provided that
)
)
9
a written agreement to adopt such child has been entered into (prior to the birth of the child)
from the moment of birth (as provided in Part IX, Section 9.18). In the case of the newborn
adopted child, however, coverage shall not be effective ifthe child is not ultimately placed in
the Subscriber's residence in compliance with Florida law.
Coverage for the newborn child of a covered Dependent of the Subscriber (other than the
spouse of the Subscriber) shall terminate 18 months after the birth of the newborn child.
In the event the Subscriber has a child, extended coverage may be available for that child
until the end of the calendar year in which the child reaches age 30, if the child meets the
following requirements:
a) The child is unmarried and does not have a Dependent of his or her own;
b) The child is a resident of Florida or a Full-Time or Part-Time Student; and
c) The child is not provided coverage as a named Subscriber, insured, enrollee or covered
person under any other group, blanket, or franchise health insurance policy or
individual health benefits plan, or is not entitled to benefits under Title XVIIl of the
Social Security Act.
d) The child is not eligible to be covered unless the child was continuously covered by
other creditable coverage without a gap in coverage of more than 63 days.
No person is eligible to enroll hereunder who has had his coverage previously terminated under
Subsection 8.01.05, except with the written approval of AvMed.
Attainment of the limiting age by a Dependent child shall not operate to exclude from or terminate the
coverage of such child, while such child is and continues to be both:
3.04.01 Incapable of self-sustaining employment by reason of mental retardation or physical
handicap; and
f)
)
3.02.07
3.02.08
o
3.03
3.04
)
Chiefly dependent upon the Subscriber for support and maintenance, provided proof of such
incapacity and dependency is furnished to AvMed by Subscriber within 31 days of the child's
attainment of the limiting age and subsequently as may be required by AvMed, bnt not more
frequently than annually after the two-year period following the child's attainment of the
limiting age.
3.05 During the term of this Contract, no changes in the Subscribing Group eligibility or requirements of
participation shall be permitted to effect eligibility or enrollment under this Contract unless such change
is agreed to by AvMed.
3.04.02
3.06 Eligible persons must reside within the continental United States, excluding Alaska and Hawaii.
,
IV. ENROLLMENT
4.0 I Prior to the effective date of this Contract and at a proper time prior to each armiversary thereof, AvMed
may allow an open enrollment period of 31 days, in which any eligible employee on behalf of himself
and his Dependents may elect to enroll in the Plan.
4.02 Except as provided for newborns, eligible employees and Dependents who meet the requirements of
Sections 3.01 and 3.02 must enroll within 31 days after becoming eligible by submitting application
forms acceptable to or provided by AvMed; otherwise, the eligible employees and Dependents may not
enroll until the next open enrollment period of the Subscribing Group.
4.03 Special Enrollment Periods
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4.03.01
4.03.02
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An eligible employee or Dependent may request to enroll in the Plan outside of the initial
enrollment period and annual open enrollment periods if that individual loses other coverage
or acquires a new Dependent as outlined below:
a) If the eligible employee or Dependent declined coverage under the Plan when it was
first offered because of other group health plan coverage or insurance coverage and
such coverage has terminated as a result of:
I) Exhaustion of COBRA continuation coverage;
2) Teonination of employment or reduction in hours of employment;
3) Termination of employer contributions;
4) Legal separation, divorce or annulment;
5) Change in Dependent status;
6) Death of an employee;
7) Change in legal custody or legal guardianship;
8) Relocation out of an HMO Service Area;
9) Attainment of lifetime maximum.
10) The eligible employee, Subscriber or Dependent must complete and submit an
Enrollment or Status Change form within 31 days of the teonination of other
coverage and provide proof of continuous coverage under the other plan. If an
employee is eligible but not enrolled, the employee will also be required to enroll at
this time.
)
- }
b) If the eligible employee or Subscriber acquires a new Dependent as a result of:
I) Marriage;
2) Birth;
3) Adoption or placement for adoption;
4) The eligible employee, Subscriber or Dependent must complete and submit an
Enrollment or Status Change form within 31 days of the date the Dependent
becomes eligible (or within 60 days as required for newborns). If an employee is
eligible but not enrolled, the employee will also be required to enroll at this time.
Employees and their Dependents who are eligible for coverage but not cnroIled, shall be
eligible to enroll for coverage within 60 days following:
a) Teonination of coverage under Medicaid or Children's Health Insurance Plan (CHIP)
due to loss of eligibi)ity; or
b) Determination of eligibility for premium assistance under Medicaid or CHIP.
c) The employee or Dependent must complete and submit an EnroIlment or Status Change
form within 60 days of the date of the loss of Medicaid or CHIP coverage, and within
60 days of the deteonination of eligibility for premium assistance under Medicaid or
CHIP. If an employee is eligible but not enrolled, the employee will also be required to
enroll at this time in order to cover an eligible Dependent.
)
11
I')
)
q
)
Tennination resulting from failure to pay premiums on a timely basis or termination of
coverage for cause (due to fraud, intentional misrepresentation, etc.) will not provide a
special el110llment period.
4.04 The eligibility requirements set forth in Part III shall at all times control and no coverage contrary
thereto shall be effective. Coverage shall not be implied due to clerical or administrative errors if such
coverage would be contrary to Part Ill. (Also see Section 16.05).
4.03.03
4.05 This Contract, at the sole option of AvMed, will not be accepted if at the time of initial offering to
Subscribing Group or, following re-enrollment, the total enrollment does not result in a predetermined
minimum el110llment as established by AvMed. The required minimum group enrollment is inclnded in
the rate letter submitted to Subscribing Group.
V. EFFECTIVE DATE OF MEMBERSHIP
Snbject to the payment of applicable monthly premium charges set forth in Part VI and to the provisions of this
Contract, coverage under this Plan shall become effective on the following dates:
5.01 Eligible employees, Subscribers and Dependents who enroll during the open enrollment period will be
covered Members as of the effective date of this Contract or subsequent anniversary thereof.
5.02 If a Subscriber acquires an eligiblc Dependent through birth, adoption, placement for adoption or
marriage, such Dependent shall be treated as covered under the Plan if, within 31 days (or as otherwise
provided for newborns in Part III) of acquiring the new Dependent, the Subscriber completes and
submits an el110llment form on behalf of such Dependent. If received by AvMed within the 31 day time
period (or 60 days as permitted for newboms), the enrollment for such Dependent shall become
effective on the date of the birth, adoption or placement for adoption, or in the case of marriage, on the
first day of the month following the date of marriage. During this period, the Subscriber and the
Subscriber's eligible spouse may also enroll for medical coverage under the Plan if not already covered.
However, if an enrollment request is not received by AvMed within the required time frame, the
Subscriber and the Subscriber's eligible Dependents will be required to wait until the next open
enrollment period to apply for coverage.
5.03 Coverage for the newborn child of the Subscriber or the newbom child of the Subscriber's covered
Dependent is effective at birth if Subsection 3.02.02(i) and Section 5.02 are complied with.
5.04 If the Subscriber or the Subscriber's Dependents originally declined medical coverage under the Plan
due to other health coverage, and that coverage is subsequently terminated as a result of either a loss of
eligibility for such coverage or the tennination of any employer contributions for such coverage, the
Subscriber and the Subscriber's Dependents will be eligible to enroll in the Plan. To enroll, you must
complete and submit an Enrollment form within 31 days of the loss of such other coverage or the
termination of employer contributions. The effective date of any coverage provided by AvMed will be
the first day of the month following the date you enroll. If the Subscriber fails to el110ll within 31 days
after the loss of other coverage, the Subscriber and the Subscriber's eligible Dependents must wait until
the next open el110llment period to apply for coverage.
5.05 If the Subscriber or the Subscriber's Dependents are eligible for coverage but not enrolled, and
experience a tennination of coverage under Medicaid or CHIP due to loss of eligibility, or are
determined to be eligible for premium assistance under Medicaid or CHIP, the Subscriber and the
Subscriber's Dependents will be eligible to enroll in the Plan. To enroll, the Subscriber must complete
and submit an enrollment form within 60 days of the loss of such coverage or the determination of such
eligibility. The effective date of any coverage provided by AvMed will be the first day of the month
12
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following the date the Subscriber enrolls. lIthe Subscriber fails to enroll within 60 days after the loss of
such coverage or the determination of such eligibility, the Subscriber and the Subscriber's eligible
Dependents must wait nntil the next open enrollment period to apply for coverage.
)
VI. MONTHLY PAYMENTS AND CO-PAYMENTS
6.01 On or before the first day of each month for which coverage is sought, Subscribing Group or its
designated agent shall remit to AvMed, on behalf of each Subscriber and his Dependents, the monthly
premium based on the rate letter and Master Application. Only Members for whom the stipulated
payment is actually received by AvMed shall be entitled to the heaIth services covered under this
Contract and then only for the period for which such payment is applicable. Failure of the Subscribing
Group to pay the premium due by the first of the month and not later than the end of the grace period (as
provided in Section 6.02) shall result in retroactive termination of the Subscribing Group, effective at
12:00 a.m. (midnight) on the last day of the month for which the premium was paid, unless the payment
of premiums has otherwise been contractually adjusted and specified by the parties in a fully executed
addendnm to this Contract. An additional charge will apply to all late premium payments. See Section
16.17.
. )
6.02 Grace period. This Contract has a ten-day grace period. This provision means that if any required
premium is not paid on or before the date it is due, it must be paid during the following grace period.
During the grace period, the Contract will stay in force. However, if payment is not received by the last
day of the grace period, termination of this Contract for nonpayment of the premium will be retroactive
to 12:00 a.m. (midnight) on the last day of the month for which the premium was paid. Note: Certain
provisions in Section 6.01 may apply if the parties have executed an addendum affecting premium
payments.
6.03 Annual out-of-pocket maximum expense limit (as describcd in your Schedule of Benefits). Co-insurance
and Co-payments you pay for benefits received during any calendar year are accumulated toward your
annual out-of-pocket maximum expense limit. Once you meet your individual or family annual out-of-
pocket maximum expense limit in any calendar year, AvMed will pay 100% of the contracted rate or
Maximum Allowable Payment, as applicable, for all covered services for the remainder of that calcndar
year.
6.03.01 Expenses that do not count toward the annual out-of-pocket maximum expense limit arc
expenses related to charges for services not covered including amounts requested for
covered services exceeding the Maximum Allowable Payment, additional amounts incurred
for failure to pre-authorize a service requiring prior authorization, expenses that relate to
services that exceed any specific treatment Limitations noted in the Schedule of Benefits,
and expenses used to satisfY the individual or family deductible.
6.04 Member shall pay premiums, applicable supplemental amounts requested, Co-payments, deductibles or
Co-insurance as provided in this Contract and applicable Schedule of Benefits. If the Member fails to
pay the applicable premiums, upon 10 days written notice from AvMed to the Member, the Member's
rights hereunder shall be terminated. Consideration for reinstatement with the Plan shall require a new
application, and any re-enrollment shall be at the sole discretion of AvMed and shall not be retroactive.
6.05 Refund of premiums paid to AvMed by the Snbscribing Group for any Member after the date on which
that Member's eligibility ceased or the Member was terminated shall bc limited to the total excess
preminm amounts paid up to a maximum of 60 days from the date of such ineligibility or tennination,
provided there are no Claims incurred subsequent to the effective date of termination. No retroactive
terminations of Members will be made beyond 60 days from notification of the terminating event.
)
13
A V-CHOICE-2009
MP-5320 (10/09)
")
)
In the event of the retroactive tennination of an individual Member (as described in Subsections 8.01.02
and 8.02.01 of this Contract), AvMed shal1 not be responsible for medical expenses incurred by AvMed
in providing benefits to the Member under the terms of this Contract after the effective date of
termination (due to the Subscribing Group's nonpayment of premiums or failure to timely notify AvMed
of Member ineligibility). At the discretion of AvMed, and based on the facts available to AvMed at the
time, AvMed may pursue either the Subscribing Group or the Member for payment.
6.06
VII. CONVERSION
A Subscriber or covered Dependent whose coverage under the Subscribing Group Contract has been
terminated for any reason, including discontinuance of the Subscribing Group Contract in its entirety or
with respect to a covered class, and who has been continuously covered under the Subscribing Group
Contract, and under any group health maintenance contract providing similar benefits which it replaces,
for at least three months immediately prior to termination, shall be entitled, subject to the exceptions
contained herein, to have issued to him or her a Conversion Contract (See Section 2.14), unless there is
a replacement of discontinued group coverage by similar group coverage within 31 days.
7.01
o
7.01.01
7.01.02
)
7.01.03
7.01.04
7.01.05
AV-CHOICE-2009
MP.5320 (10/09)
The converting Subscriber and each of the eligible Dependents of the Subscriber who are
converting must be Members of the Plan in good standing on the date when their coverage
terminates under this Group Contract, and all such Subscribers and Dependents, after
complying with Subsection 7.01.02 below, shall be covered under the Individual Conversion
Contract.
A completed Status Change form requesting conversion shall be sent to AvMed or its
designated administrator with the first applicable premium and shall be received by AvMed
or its designated administrator not later than 63 days after the date of termination of this
Group Contract.
Dependents may not convert without the Subscriber except:
a) In the event of the death of the Subscriber, Dependents are permitted an automatic
conversion privilege and must comply with Subsection 7.01.02 above; or
b) A spouse whose coverage would terminate, or a spouse and children whose coverage
would otherwise terminate at the same time, or a child with respect to himself, by
reason of ceasing to be a qualified family member, may convert and must comply with
Subsection 7.01.02 above; or
c) A former spouse whose coverage would otherwise terminate because of annulment or
dissolution of marriage may convert if the former spouse is dependent for financial
support. The former spouse must comply with Subsection 7.01.02 above and must
provide written evidence of financial dependence upon request of AvMed.
Payment for health care services rendered to a Member after termination and prior to
conversion shall be the responsibility of the Member. When the conversion application has
been timely completed (within 63 days after termination of the Group Contract) and the first
premium duc has been paid, AvMed shall reimburse the Subscriber for any payment made by
the Subscriber for covered Medical Services under the converted Contract.
A new Conversion Contract is established upon application and payment of the premium on
the day following the Member's termination from group coverage (due to ineligibility under
the Group Contract) and continues through the end of the calendar year. The Contract Year,
upon renewal, shall be the calendar year.
14
)
7.02 Individual Conversion Contracts may not include supplemental benefits, notwithstanding the
supplemental benefits included under this Subscribing Group Contract, and may in other respects, as
determined by AvMed, differ from this Group Contract.
7.03 The conversion privilege will not apply to a Subscriber or covered Dependent if termination of coverage
under this Contract occurred for any of the following reasons:
7.03.01
7.03.02
7.03.03
7.03.04
7.03.05
7.03.06
)
Failure to pay any required premium or contribution unless such nonpayment of premium
was dne to acts of an employer or person other than the individual;
Replacement of any discontinned group coverage by similar group coverage within 31 days;
Frand or material misrepresentation in applying for any benefits under this Contract; (See
Subsection 8.01.05);
Willful and knowing misnse of AvMed's identification card by the Member;
Willfully and knowingly furnishing incorrect or incomplete information to AvMed for the
purpose of fraudulently obtaining coverage or benefits from AvMed; or
Termination from coverage under this Contract in accordance with Subsection 8.01.05.
.)
7.04 Convc."sion after Continuation Coverage. When continuation coverage as provided under the
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) expires, the
Subscriber or covered Dependent may be eligible for conversion coverage and may apply by completing
an application for an Individual Conversion Contract, subject to the conditions described in this Part
VII. The eligible Subscriber or Dependent must send a completed application and the applicable
premium payment, postmarked not later than 63 days after the termination of COBRA coverage, directly
to:
7.04.01
7.04.02
AvMed
Accounts Receivable Department
Suite510
9400 South Dadeland Blvd.
Miami, Florida 33156
)
The Subscriber or Dependent may obtain an application form and a statement of current
premium rates for the Individual Conversion Contract by calling AvMed Member Services.
It is the responsibility of the Subscribing Group to notify Subscriber of Subscriber's rights
under COBRA. For any specific questions concerning COBRA, contact the Subscribing
Gronp.
VIII. TERMINATION
All rights and benefits under this Contract shall cease as of the effective date of termination, unless otherwisc
provided herein.
This Contract shall continue in effect for one year from the effective date hereof and may be renewed from year
to year thereafter, subject to the following termination provisions. All rights to benefits under this Contract shall
cease at 12:00 a.m. (midnight) on the effective date oftennination.
8.0 I Reasons for Tennination:
8.01.01
A V-CHOlCE-2009
MP-5320 (10/09)
Loss of Eligibility. Subject to the conversion rights under Section 7.02:
15
f")
)
8.01.02
10
8.01.03
)
8.01.04
A V-CHOICE-2009
MP-5320 (10/09)
a) Upon a loss of the Subscriber's or Dependent's eligibility as defined in Part III,
coverage shall automatically tenninate on the last day of the month for which the
monthly premium was paid and during which the Subscriber and/or Dependent was
eligible for coverage.
b) Coverage for all Dependents shall automatically terminate on the last day of the month
for which the monthly premium was paid upon a loss of the Subscriber's eligibility, as
defined in Part III.
Failure to Make Premium Payment. Upon failure of the Subscribing Group to make payment
of the monthly premium provided in Part VI within 10 days following the due date specified
herein, benefits hereunder shall terminate, for all Subscribers and any Dependents for whom
such payment has not been received, at 12:00 a.m. (midnight) on the last day of the month
for which the monthly premium was paid.
a) AvMed, regarding cancellation or non-renewal of this coverage, may retroactively
cancel the policy to the date for which the Subscribing Group's premiums have been
paid, when AvMed provides notice of cancellation or non-renewal to the Subscribing
Group prior to 45 days after the date the premium was due. AvMed will include a
reason for the Contract termination in its written notification to the Subscribing Group.
The Subscribing Group will forward such notification to all Subscribers when AvMed
has notified the Subscribing Group of the cancellation or non-renewal, and AvMed is
deemed to have complied with its notification requirements by providing said notice to
the Subscribing Group.
Termination of Group Contract by Subscribing Group. Subscribing Group may terminate
this Group Contract on the anniversary date by giving written notice to AvMed 15 days prior
to Contract anniversary date. In such event, benefits hereunder shall tenninate for all
Members at 12:00 a.m. (midnight) on the Contract expiration date as described below.
a) Early Termination of Group Contract by Subscribing Group. Subscribing Group may
terminate this Group Contract by giving at least 60 days written notice to AvMed. In
such event, benefits hereunder shall terminate for all Members at 12:00 a.m. (midnight)
on the date specified by the Group in their written notice to AvMed and for which
premium was paid.
Tennination of Group Contract by AvMed. AvMed may non-renew or discontinue this Group
Contract based on one or more of the conditions listed below. In such event, benefits
hereunder shall terminate for all Members at 12:00 a.m. (midnight) on the Contract
expiration date as described below.
a) Subscribing Group has failed to pay premiums or contributions in accordance with the
terms of this Contract or AvMed has not received timely premium payments (See Part
VI, Monthly Payments and Co-payments and Subsection 8.01.02). Termination of
coverage will be effective on the last day of the month for which payments were
recoived by AvMed.
b) Subscribing Group has performed an act or practice that constitutes fraud or made an
intentional misrepresentation of material fact under the terms of this Contract. This will
result in immediate termination of Subscribing Group.
c) Subscribing Group has failed to comply with a material provision of the Contract that
relates to rules for employer contributions or group participation. Termination will be
effective upon 45 days written notice from AvMed to Subscribing Group.
16
d) There is no longer any enrollee in connection with the Plan who lives, resides, or works
in the Service Area. Termination of coverage will be effective on the last day of the
month for which payments were received by AvMed.
e) AvMed ceases to offer coverage in the applicable market. AvMed will provide written
notice to Subscribing Group at least 180 days prior to such termination.
Termination of Coverage for Cause. AvMed may terminate any Member immediately upon
written notice for the following reasons which lead to a loss of eligibility of the Member:
a) Fraud, material misrepresentation, or omission in applying for membership, benefits, or
coverage under this Contract. However, relative to a misstatement in the Application,
after two years from the issue date, only fraudulent misstatements in the Application
may be used to void the policy or deny any claim for a loss occurred or disability
starting after the two year period;
b) Misuse of AvMed's identification card furnished to the Member;
c) Furnishing to AvMed incorrect or incomplete information for the purpose of obtaining
membership, coverage, or benefits under this Contract; or
d) Behavior which is disruptive, unruly, abusive, or uncooperative to the extent that the
Member1s continuing coverage under this Contract seriously impairs AvMed's ability to
administer this Contract or to arrange for the delivery of health care services to the
Member or other Members after AvMed has attempted to resolve the Member's
problem.
e) At the effective date of such termination, premium payments received by AvMed on
account of such tennination shall be refunded on a pro rata basis, and AvMed shall have
no further liability or responsibility for the Member under this Contract.
Notification Requirements:
Loss of eligibility of Subscriber. it is the responsibility of Subscribing Group to notify
AvMed in writing within 31 days from the effective date of tennination regarding any
Subscriber and/or Dependent who becomes ineligible to participate in the Plan. Failure of
the Subscribing Gronp to provide timely written notice as described above may lead to
retroactive tenllination of the Subscriber and/or Dependent. The effective date for slich
retroactive termination will be the last day of the month for which the premium was paid and
during which the Subscriber and/or Dependent was eligible for coverage. See Section 6.06.
Loss of cligibility of Dependent. When a Dependent becomes ineligible for Dependent
coverage, the Subscriber is required to notify AvMed in writing within 31 days of the
Dependent becoming ineligible.
Contract Termination. In the event this Contract is terminated, the Subscribing Group agrees
that it shall provide 45 days prior written notification of the date of such termination to its
employees who are Subscribers covered under this Contract.
In no event will any retroactive termination of a Member be made beyond 60 days from
notification of the terminating event.
8.03 Certificates of Coverage. If your coverage under the Plan ends, you will automatically receive a
Certificate of Group Health Plan Coverage. You may take this certificate to another health care plan to
receive credit for your coverage under the Plan. You will only need to do this if the other health care
plan has a pre-existing condition limit. You can request a Certificate of Group Health Plan Coverage
anytime during the 24-month period after the date your coverage under the Plan has ended.
8.01.05
8.02
8.02.01
8.02.02
8.02.03
8.02.04
A V-CHOlCE-2009
MP-5320 (10/09)
)
)
, )
)
17
f)
)
8.04
q
)
Continuation Coverage under COBRA. Under certain provisions of COBRA, the Subscriber or his
Dependents may elect continued coverage under the Plan if coverage is lost due to a qualifying event.
8.04.01 Eligibility. You or your covered Dependents will become eligible for continuation coverage
under COBRA after any of the following qualifying events result in the loss of Plan
coverage:
a) Loss of benefits due to a reduction in your hours of employment;
b) Termination of your employment, inclnding retirement but excluding termination for
gross misconduct;
c) Termination of employment following leave under the Family and Medical Leave Act
of 1993 (FMLA), in which case the qualifying event will occur on the earlier of the date
you indicated you were not retuming to work or the last day of the FMLA leave;
d) You or a Dependent first become entitled to Medicare or covered under another group
health plan prior to your loss of coverage due to termination of employment or
reduction in hours.
8.04.02
8.04.03
e) In addition, your Dependents will become eligible for COBRA continuation coverage
after any of the following qualifying events occur to cause a loss of Plan coverage:
I) Your death;
2) Your divorce or legal separation;
3) You first become entitled to Medicare after your loss of coverage due to termination
of employment or reduction in hours; or
4) Your Dependent child no longer qualifies as a Dcpendent under the Plan.
l) A child who is bom to (or placed for) adoption with a covered former employee during
the continuation coverage period has the same continuation coverage rights as a
Dependent child described above.
Notification. If a qualifying event other than divorce, legal separation, loss of Dependent
status or entitlement to Medicare occurs, the Plan Administrator will be notified of the
qualifying event by your employer and will send you an election fonn. To continue Plan
coverage, you must return the election form within 60 days from the later of the date you
receive the form, or the date your coverage ends due to a qualifying event.
a) If divorce, legal separation, loss of Dependent status or entitlement to Medicare under
the Plan occurs, you or your covered Dependent must notify the Plan Administrator that
a qualifying event has occurred. This notification must be reccived by the Plan
Administrator within 60 days after the later of the date of such event, or the date you or
your eligible Dependent would lose coverage on account of such event. Failure to
promptly notify the Plan Administrator of these events will result in loss of the right to
continue coverage for you and your Dependents.
b) After receiving this notice, the Plan Administrator will send you an election form within
14 days. If you or your Dependents wish to elect continuation coverage, the election
form must be retumed to the Plan Administrator within 60 days from the later of the
date you receive the form or the date your coverage ends due to the qualifying event.
Cost. If you elect to continue coverage, you must pay the entire cost of coverage (the
employer's contribution and the active employee portion of the contribution), plus a 2%
administrative fee for the duration of COBRA continuation coverage.
18
A V-CHOlCE-2009
MP-5320 (10/09)
8.04.04
AV-GIOICE-2009
MP-5320 (10/09)
)
a) If you or your Dependent is Social Security disabled (Social Security disability status
must occur as defined by Title II or Title XVI of the Social Security Act), you may elect
to continuc coverage for the disabled person only or for some or all of COBRA eligible
family members for up to 29 months if your employment is terminated or your hours
are reduced. You must pay 102% of the cost of coverage for the first 18 months of
COBRA continuation coverage and 150% of the cost of coverage for the 19th through
the 29th months of coverage. The Social Security disability date must occur within the
first 60 days of loss of coverage due to your termination of employment or reduction in
hours.
)
b) For COBRA coverage to remain in effect, payment must be received by the Plan
Administrator by the first day of the month for which the premium is due. (Your first
payment is due no later than 45 days after your election to continue coverage, and it
must cover the period of time back to the first day of your COBRA continuation
coverage.)
Duration. COBRA Continuation Coverage can be extended for:
a) 18 months if coverage ended due to a reduction in your work hours or termination of
your employment and you or one of your covered Dependents is not Social Security
disabled within 60 days of the date you lose coverage due to termination of employment
or reduction in hours, the Medicare entitled person may elect up to 18 months of
COBRA. If you are that Medicare entitled person, your Dependents may elect COBRA
for the longer of 36 months from your prior Medicare entitlement date, or 18 months
from the date of yOU! termination or reduction in hours; or
b) 36 months for your Dependents, if your Dependents lose eligibility for medical
coverage due to your death, your divorce or legal separation, your entitlement to
Medicare after your termination or reduction in hours, or your Dependent child ceasing
to qualify as a Dependent under the Plan; or
c) 29 months if you lose coverage due to a tennination of employment or reduction in
hours and yon or a Dependent is disabled, as defined by Title II or Title XVI of the
Social Security Act, within 60 days of the original qualifying event. In this case, you
may continue covera~e for an additional II months after the original 18-month period
either for the disabled person only or for one or all of your covered family members.
d) To be eligible for extended coverage due to Social Security disability, you must notify
the Plan Administrator of the disability before the end of the initial 18 months of.
COBRA continuation coverage and within 60 days following the date you or a covered
Dependent is detennined to be disabled by the Social Security Administration. If the
disabled individual should no longer be considered to be disabled by the Social Security
Administration, you must notify the Plan Administrator within 30 days following the
end of the disability. Coverage that has exceeded the original 18-month continuation
period will end when the individual is no longer Social Security disabled.
e) If more than one qualifying event occurs, no more thaIl 36 months total of COBRA
continuation coverage will be available. The COBRA beneficiary mnst experience the
second qualifying event during the first 18 months of COBRA continuation, and mnst
provide notice to the Plan Administrator within the required time period. COBRA
continuation coverage will end sooner if the Plan terminates and the employer does not
provide replacement medical coverage, or if a person covered under COBRA:
I) First becomes covered under another group health plan after the loss of coverage
due to your termination or reduction in hours, unless the new group coverage is
~l
)
19
t")
)
limited due to a pre-existing condition exclnsion; this Plan will be primary for the
pre-existing condition and secondary for all other eligible health care expenses,
provided contributions for COBRA coverage continue to be paid. Coverage may
only continue for the remainder ofthe original COBRA period;
2) Fails to make required contributions when due;
3) First becomes entitled to Medicare benefits after the initial COBRA qualifying
event; or
4) Is extending the 18-month coverage period because of disability and is no longer
disabled as defined by the Social Security Act.
8.05 Continuation Coverage during Leaves of Absence.
8.05.01
(.)
\
}
Family and Medical Leaves of Absence (FMLA). Under FMLA, you may be entitled to up
to a total of 12 weeks of unpaid, job-protected leave during each calendar year for the
following:
a) the birth of your child, to care for your newbom child, or for placement of a child in
your home for adoption or foster care;
b) to care for your spouse, child or parent with a serious health condition; or
c) for your own serious health condition.
d) If your FMLA leave is a paid leave, your pay will be reduced by your before-tax
contributions as usual for the coverage level in effect on the date your FMLA leave
begins. If your FMLA leave is unpaid, you will be required to pay your contributions
directly to the employer until you return to active pay status.
e) If you notify your employer that you are terminating employment during your FMLA
leave, your coverage will end on the date of your notification. If you do not return to
work on your expected FMLA return date, and you do not notify your employer of your
intent either to terminate your employment or to extend the period of leave, your
coverage will end on the date you were expected to return.
f) You may not change your Plan elections during your FMLA leave unless an open
enrollment occurs or you are on a paid FMLA leave and you have a change in status
event or a special enrollment event under The Health Insurance Portability and
Accountability Act of 1996 (HlPAA).
Military leaves of absence. If you are absent from work due to military service, you may
elect to continue coverage under the Plan (including coverage for enrolled Dependents) for
up to 18 months from the first day of absence (or, if earlier, until the day after the date you
are required to apply for or retum to active employment with your employer under the
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)). Your
contributions for continued coverage will be the same as for similarly situated active
participants in the Plan.
a) Whether or not you continue coverage during military service, you may reinstate
coverage under the Plan option you elected on your return to employment under
USERRA. The reinstatement will be without any waiting period otherwise required
under the Plan, except to the extent that you had not fully completed any required
waiting period prior to the start of the military service.
8.06 Conversion after Continuation Coverage. See Section 8.04.
8.05.02
A V-CHOICE-2009
MP-5320 (10/09)
20
)
8.07 Extension of benefits. In the event this Contract is terminated for any reason, except nonpayrnent of
premium or as set forth in Subsection 8.07.03, such termination shall be without prejudice to any
continuous losses to a Member which commenced while this Contract was in force, but any extension of
benefits beyond the date of termination shall be predicated upon the continnous Total Disability as
defined in Section 2.56, of the Member and shall be limited to payment for the treatment of a specific
accident or illness incurred while the Member's coverage under this Contract was effective.
8.07.01
8.07.02
8.07.03
)
The extension of benefits covered under this Contract shall be limited to the occurrence of
the earliest of the following events:
a) The expiration of 12 months;
b) Such time as the Member is no longer totally disabled;
c) A succeeding carrier elects to provide replacement coverage without Limitation as to
the disability condition; or
d) The maximum benefits payable under this Contract have been paid.
In the case of maternity coverage, when not covered by the succeeding carrier, a reasonable
extension of this Contract1s benefits will be provided to cover maternity expenses for a
covered pregnancy that commenced while the policy was in effect. The extension shall be
for the period of that pregnancy only and shall not be based upon Total Disability.
Except as provided above, no Subscriber is entitled to an extension of benefits if the
termination by AvMed of this Contract is based upon one or morc of the following reasons:
a) Fraud or intentional misrepresentation in applying for any benefits under this Contract;
b) Disenrollment for cause; or
c) The Subscriber has left the geographic Service Area of AvMed with the intent to
relocate or establish a new residence outside AvMed's Service Area.
}
)
IX. SCHEDULE OF BASIC BENEFITS
The A vMed Choice product has several special features that can influence the level of coveragc and how much
you payout of pocket for medical care. Your choice of Health Professional and/or facility may result in lower
or higher costs and you may be required to follow certain procedures to avoid additional costs. Your choice of
Health Professional and/or facility, and wise use of these benefits, can savc you money.
Within the Service Area, Members are entitled to receive the covered services and benefits through the AvMed
Choice Network or from Out-of-Network Providers. Outside the AvMed Service Area, Members are entitled to
receive the covered services and benefits either through the PHCS Network or through Out-of-Network
Providers. See the Schedule of Benefits for applicable deductibles, Co-payments and Co-insurance levels.
The AvMed Choice Plan creates three benefit payment levels; one for services provided by AvMed Choice
providers, a second for services provided by PHCS providers and a third for services provided by Out-of-
Network Providers. The Benefit Level this Group Plan will pay depends on the Health Professional and/or
facility you select to provide covered health care services and where the services are received:
. If the Health Professional and/or facility used is part of the A vMed Choice Network, benefits for covered
services are payable at the Participating Provider high Benefit Level shown in the Schedule of Benefits.
AV-CHOtCE-2009
MP-5320 (10/09)
21
')
)
()
. If the Health Professional and/or facility used is part of the PHCS Network, covered serviccs are payable at
the middle Benefit Level specified in the Schedule of Benefits. The PHCS Network is not available within
the AvMed Service Area.
. If the Health Professional and/or facility used is an Out-of-Network Provider, benefits for services covered
are payable at the low Benefit Level as specified in the Schedule of Benefits.
An important feature of this Point of Service Plan is that the amount of your out-of-pocket expense is
detelmined by your choice of provider at the time services are sought:
. Members choosing AvMed Choice providers will be responsible for paying lower Co-payments and/or Co-
insurance.
. Members choosing Providers from the PHCS Network while outside the A vMed Service Area will be
responsible for paying mid-level Co-payment and/or Deductible and Co-insurance amounts.
. Members choosing Out-of-Network Providers will pay the highest Deductibles and Co-insurance amounts
and will also be at risk for provider fees that are in excess of allowable amounts. In other words, a Member
who chooses an Out-of-Network Provider may be responsible to pay the amount that exceeds the Maximum
Allowable Payment for the particular medical service involved in addition to the applicable Deductible and
Co-insurance amounts. Also, fees that are in excess of allowable amounts are not a covered benefit and
therefore do not apply to your Deductible or annual out-of-pocket expense.
It is the Member's responsibility when seeking benefits uuder this Contract to identifY himself as an AvMed
Member and to verifY that the provider chosen is still a contracted provider of the selected network, if any.
Any Member requiring medical, Hospital, or ambulance services for emergencies (as described in Subsections
2.20.01 and 2.20.02), either while outside the Service Area or within the Service Area but before they can reach
a Participating Provider, may receive the emergency benefits as specified in Section 9.11.
Only services and beuefits in conformity with Part II (Definitions), Part IX (Schedule of Basic Benefits), Part X
(Limitations of Basic Benefits), Part XI (Exclusions from Basic Benefits) and the Schedule of Benefits, which
by reference is incorporated herein, are covered by AvMed.
Members must understand that services will not be covered if they are not, in AvMed's opinion, Medically
Necessary. Any and all decisions made by AvMed in administering the provisious of this Contract, including
without limitation, the provisions of Part IX (Schedule of Basic Benefits), Part X (Limitations of Basic
Benefits), and Part XI (Exclusions from Basic Benefits), are made only to determine whether payment for auy
benefits will be made by AvMed.
Any and all decisions that pertain to the medical need for, or desirability of the provision or non-provision of
Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services
or benefits, must be made solely by the Member and his physician, in accordance with the normal
patient/physician relationship for purposes of determining what is in the best interest of the Member.
AvMed does not have the right of control over the medical decisions made by the Member's physician or health
care providers. The ordering of a service by a physician, whether participating or non-participating, does not in
itself make such service Medically Necessary. Subscribing Group and Member acknowledge that it is possible
that a Member and his physician may determine that such services or supplies are appropriate even though such
services or supplies are not covered and will not be amU1ged or paid for by A vMed. Any covered service for
which the member is seeking reimbursement, must be submitted to the Plan within one year from the date of
service to be considered.
Cost-Sharing Information
Deductible. In some instances, you mllst satisfy the annual Deductible specified in the Schedule of Benefits
before A vMed will begin paying expenses for services covered. The Deductible means the amount a Member
must pay each calendar year for covered services before A vMed will make payment for eligible expenses. The
22
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individual Deductible or family Deductible must be satisfied each calendar year before any payment for certain
services and medications will be made by AvMed for any Claim. The Deductible is accumulated across all
levels. Satisfaction of the Deductible under one Benefit Level will count toward satisfaction of the Dednctible
under the other Benefit Levels.
If two or more covered Members of a family incur injury due to the same accident, the Deductible applies only
once for all such expenses. If during a calendar year, the covered Members of a family incur eligible expenses
for which no benefits are payable because of the Deductible requirements and the amount of such eligible
expense equals the family Deductible limit, then no further Deductible will apply to the covered Members of the
family during the remainder of such calendar year.
Any eligible expenses credited by AvMed toward your Deductible requirement during the last three months of
this Group Plan's prior calendar year, will be reduced to the extent of such application for the next ensuing
calendar year.
Only those eligible expenses submitted on Claims to AvMed will be credited toward the Deductible. Expenses
that are not eligible expenses will not be counted toward the satisfaction of the Deductible.
Co-insurance. Once the calendar year Deductible has been met, you arc responsible for paying a percentage of
eligible expenses. The coverage percentage, hereinafter called 'Co-insurance' is specified in the Schedule of
Benefits. You will be responsible for paying any charges not considered an eligible expense.
Annual Out-of-Pocket Maximum Limits. Co-insurance and certain Co-payments you pay for benefits
received during any calendar year under this Plan are accumulated toward your annual out-of-pocket maximum
limit. Once you meet your individnal or family out-of-pocket maximum limit in any calendar year, the Plan will
pay 100% of the contracted rate or Maximum Allowable Payment, as applicable, for all covered services for the
remainder of that calendar year.
Expenses that do not count toward the annual out-of-pocket maximum limit are expenses related to services not
covered by this Point of Service Plan, additional amounts incurred for failure to pre-authorize a service requiring
prior authorization, expenses that relate to services that exceed any specific treatment Limitations noted in the
Schedule of Benefits, and expenses used to satisfY the individual or family deductible.
Lifetime Maximum Benefit. While this Group Plan stays in force, the eligible expenses incurred by a Member
are limited to the applicable maximum shown in the Schedule of Benefits. When benefits in snch amount have
been paid or are payable under this Plan, all coverage will terminate for the Member.
Effect of Prior Coverage. The following provision applies to Members who, on the day before the effective
date of this Plan, were covered under prior coverage. Prior coverage means the policyholder's group medical
plan that this Group Plan replaced. AvMed will automatically cover any such person under this Group Plan on
its effective date, subject to the following provision.
Those persons eligible according to the terms of this Group Plan wiIl be covered at the level of benefits of this
Group Plan. This includes persons who were covered under a continuation provision of the prior coverage to
the extent it was required by state or federal law. This continued coverage under this Group Plan will ternlinate
on the date that coverage would have terminated according to the law under the prior coverage, had the prior
coverage remained in force.
)
.J
)
Deduetible Carryover. Any expenses incurred by a Member while covered under the prior coverage will be
credited toward satisfaction of the Deductible under this Plan if:
. The expenses were incurred during the 90 day period before the effective date of the Group Plan;
. The expenses were applied toward satisfaction of the Deductible under the prior coverage during the 90-day
period before the effective date of this Group Plan; and
. The expenses would be considered eligible expenses under this Group Plan.
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If)
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However) in order to receive credit) you must supply evidence of satisfaction of the Deductible under the prior
coverage by providing A vMed written proof of what has been paid by prior coverage.
Prior Authorization of Covered Services
Before a service is performed, you should verify with your provider that the service has received prior
authorization. If you are unable to secure verification from your provider, you may also call AvMed. Please
remember that failure to obtain prior authorization of a service will result in a reduction in coverage as
shown in the Schedule of Benefits. This reduction will occur regardless of whether such services are deemed
Medically Necessary. If an inpatient admission is extended beyond the number of days approved, without
authorization, benefits for the extra days will be denied.
If your physician is an AvMed Choice Provider, then he or she will handle all authorizations, notifications and
utilization reviews with AvMed. If your physician is not an AvMed Participating Physician, you are responsible
for making sure your physician or Health Professional contacts AvMed to obtain prior authorization for a
covered service when it is required. Please refer to your Member identification card for the telephone number
where authorization may be obtained, or have your physician call 1-800-443-41 03.
The following services require prior authorization from AvMed:
. All inpatient admissions (including Hospital and observation stays, skilled nursing facilities, ventilator
dependent care, and/or acute rehabilitation).
.. Dialysis services.
. Transplantation services.
. Certain medications including injectables
For more information about which services require prior authorization, contact AvMed at 1-800-882-8633,
AvMed requires pre-service notification before you receive certain covered services. Complex diagnostic
testing procedures which require pre-service notification include but are not limited to CT, CT A, MR.I, MRA,
and PET Scans, Nuclear Cardiac Studies, and Nuclear Medicine.
The names and addresses of Participating Providers and Hospitals are set forth in a separate booklet which, by
reference, is made a part hereof. The list of Participating Providers, which may change from time to time, will
be provided to all Subscribing Groups. The list of Participating Providers may also be accessed from the
A vMed website at www.avmed.org. Notwithstanding the printed booklet, the names and addresses of
Participating Providers on file with AvMed at any given time shall constitute the official and controlling list of
Participating Providers. Also, a list of the PHCS contracted providers is available through a link on the
www.avmed.org website or by calling AvMed's Member Services department. Pursuant to Florida Statute,
there is a link available on the A vMed website to view the performance outcome and financial data that is
published by the Florida Agency for Health Care Administration.
Members are encouraged but not required to select a Primary Care Physician (PCP) upon enrollment. You can
change your PCP selection at any time, but no more often than once per month. You must notify and receive
approval from AvMed prior to changing your PCP. Such change will become effective on the first day of the
month after you notifY AvMed. Health Professionals may from time to time cease their affiliation with AvMed
or PHCS. You should confirm participation of your selected provider prior to seeking services.
MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR APPLICABLE CO-PAYMENTS,
DEDUCTIBLES AND/OR CO-INSIDUNCE WHICH MUST BE PAID TO HEALTH CARE
PROVIDERS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE RENDERED, AS SET
FORTH IN THE SCHEDULE OF BENEFITS.
9.01 Ambulance services as follows:
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Local professional air/ground ambulance transport for emergency services to the nearest
emergency department appropriately staffed and equipped to treat a medical condition;
Ground transportation to an alternative level of care when associated with an approved
Hospital confinement; and
Ground transportation to a Member's home will be covered when associated with an
approved hospitalization or other confmement and the Member's condition requires the skill
of medically trained personnel. Transportation is not covered when the skill of medically
trained personnel is not required and the Member can be safely transferred (or transported)
by other means.
Air ambulance transportation is covered only when the point of pick-up is inaccessible by
land or when distance or other obstacles are involved in transporting the Member to the
nearest emergency department equipped to adequately treat the medical condition.
9.02 Cardiac rchabilitation. Cardiac rehabilitation is covered for the following conditions: acute myocardial
infarction, percutaneous transluminal coronary angioplasty (pTCA), coronary artery bypass graft
(CABG), repair or replacement of heart valves or heart transplant. Coverage is subject to a maximum
number of visits per calendar year as outlined in the Schedule of Benefits. See Schedule of Benefits for
detailed information regarding Co-payments and coverage Limitations.
9.01.01
9.01.02
9.01.03
9.01.04
)
)
, }
9.03 Coverage for cleft lip and cleft palate for Members under 18 years of age. The coverage provided
by this Section is subject to the terms and conditions applicable to other benefits.
9.04 Dermatological services. AvMed will cover office visits to a dermatologist for Medically Necessary
covered services subject to Sections 2.36 and 2.60. No prior referral is reqnired for these services.
9.05 Diabetes treatment includes all Medically Necessary equipment, supplies, and services to treat
"diabetes. This includes outpatient self-management training and educational services, if the Member's
physician certifies the equipment, supplies or services are Medically Necessary. Insulin pumps are
covered under Subsection 9.10.05. Diabetes outpatient self-management training and educational
services must be provided under the direct supervision of a certified diabetes educator or a board
certified endocrinologist. In accordance with Florida Statutes, coverage of insulin pumps for the
treatment of diabetes will not apply toward or be subject to the annual DME maximum Limitation. See
also 9.06.
)
9.06 Diabetic supplies. Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing
Group's supplemental prescription medication benefits. In the event that a Snbscribing Gronp does not
purchase supplemental prescription medication benefits, insulin, insulin syringes, lancets, and test strips
are covered subject to a 30% Co-insurance per item for a 30-day supply. See also 9.05.
9.07 Diagnosis and treatment of Autism Spectrum Disorder through speech therapy, occnpational therapy,
physical therapy, and Applied Behavior Analysis services for an individual under 18 years of age or an
individual 18 years of age or older who is in high school who has been diagnosed as having a
developmental disability at 8 years of age or younger.
9.07.01
9.07.02
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Coverage shall be limited to services that are prescribed by the treating physician in
accordance with a treatment plan. The treatment plan required shall include, but is not
limited to, a diagnosis, the proposed treatment by type, the frequency and duration of
treatment, the anticipated outcomes stated as goals, the frequency with which the treatment
plan will be updated, and the signature of the treating physician. Coverage for these services
shall be limited to $36,000 annually and may not exceed $200,000 in total benefits.
Coverage is subject to applicable Co-payments and coverage Limitations as set forth in the
Schedule of Benefits.
25
f)
)
Diagnostic imaging and laboratory. All prescribed diagnostic imaging and laboratory tests and
services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and other
laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and
ordered by a physician as part of the diagnosis and/or treatment of a covered illness or injury or as
preventive health care services.
9.09 Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADIID).
Coverage is subject to applicable Co-payments and coverage Limitations as outlined in the Schedule of
Benefits. Covered services do not include those that are primarily educational or training in nature.
9.08
9.10 Durable Medical Eqnipment (DME). This Contract provides benefits, when Medically Necessary, for
the purchase or rental of such DME that:
o
9.10.01
9.10.02
9.10.03
9.10.04
9.10.05
Can withstand repeated use (i.e. could normally be rented and used by snccessive patients);
Is primarily and customarily used to serve a medical purpose;
Generally is not useful to a person in the absence of illness or injury; and
Is appropriate for use in a patienCs home.
Some examples of DME are: hospital beds, crutches, canes, walkers, wheelchairs,
respiratory equipment, apnea monitors and insulin pumps. It does not include hearing aids
or corrective lenses, or the professional fee for fitting same. It also does not include medical
supplies and devices, such as a corset, which do not require prescriptions. AvMed will pay
for rental of equipment up to the purchase price. Repair and/or replacements arc not
covered. See Schedule of Benefits for any Co-payments or Limitations. See Part XII for
Exclusions.
Oxygen is covered when Medically Necessary pursuant to AvMed's coverage guidelines,
which are available free of charge upon request. The type of oxygen delivery system
covered (stationary, portable, ambnlatory) is based on the Member's activity status. Initial
coverage is contingent upon arterial blood gas results. Reassessment of oxygen needs
through pulse oximetry at rest and after exercise is required and must be performed by an
independent respiratory provider at three months after the initiation of therapy and then
yearly in order to re-qualify coverage of oxygen therapy.
The determination of whether a covered item will be paid under the DME, orthotics or
prosthetics benefits will be based upon its classification as defined by the Centers for
Medicare and Medicaid Services. See Schedule of Benefits for applicable Co-payments and
coverage Limitations. See Part XI for Exclnsions.
9.11 Emergency services. AvMed will cover all necessary physician and Hospital Services for Emergency
Medical Services and Care (See Section 2.19). In the event that Hospital inpatient services are provided
following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member
or designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may elect to
transfer the Member to a participating provider as soon as it is medically appropriate to do so. If the
Member chooses to stay in the Non-participating facility after the date AvMed decides a transfer is
medically appropriate, out-of-network benefits may be available if the continued stay is determined to
be a covered health service. In addition, any Member requests for reimbursement (of payment made by
the Member for services rendered) must be filed within 90 days after the emergency or as soon as
reasonably possible but not later than one year unless the Claimant was legally incapacitated.
9.10.06
9.10.07
9.12 General anesthesia and hospitalization services to a Member who is under 8 years of age and is
determined by a licensed dentist and the Member's physician to require necessary dental treatment in a
Hospital or ambulatory surgical center due to a significantly complex dental condition or a
A V-CHOlCE-2009
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26
9.13
9.14
9.15
)
developmental disability in which patient management in the dental office has proved to be ineffective;
or if the Member has one or more medical conditions that would create significant or undue medical risk
for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in
a Hospital or ambulatory surgical center. Pre-authorization by AvMed is required. There is no coverage
for diagnosis or treatment of dental disease.
Home Health Care Services (Skilled Horne Health Care). Home Health Care Services (as defined in
Section 2.25) are covered as outlined on the Schedule of Benefits when ordered by and nnder the
direction of the Member's Attending Physician. Physical, occupational or speech therapy services
provided in the home are limited as noted in Sections 9.27 and 9.31. Home Health Care Services that do
not include a medical, diagnostic, therapeutic or rehabilitative component, or that do not require the skill
of a registered nurse, licensed practical (vocational) nurse or other healthcare persOImel arc not covered.
Homemaker or other Custodial Care services are not covered.
)
IIospitaI care: inpatient. All Hospital inpatient services received at Participating Hospitals for non-
mental illness or injury are provided when prescribed by your physician and pre-authorized by AvMed.
Inpatient services include semi-private room and board, birthing rooms, newborn nursery care, nursing
care, meals and special diets when Medically Necessary, use of operating rooms and related facilities,
intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests, medications,
biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory therapy, and
administration of blood or blood plasma. See Section 9.11 with regard to inpatient admission following
Emergency Medical Services and Care.
- )
Hospital bascd providers will be paid as follows.
a) For non-emergency services, the level of payment for Hospital Based Providers who are
considered Out-of-Network Providers because they do not contract with A vMed or the
plICS Network, will be determined subject to the following criteria:
I) If services are performed at an AvMed Choice Network Hospital and the admitting
physician is also part of the AvMed Choice Network, then the Hospital Based
Provider will be paid at the highest level of benefits.
2) If services are rendered at an A vMed Choice Network Hospital and the admitting
physician is not part of the A vMed Choice Network, then the Hospital Based
Provider will be paid at the middle level of benefits.
3) If services are rendered at a PHCS Hospital, then the Hospital Based Provider will
be paid at the middle level of benefits.
4) If services are rendered at an out-of-network Hospital, then the Hospital Based
Provider will be paid at the low level of benefits.
Hospice scrvices. Services are available for a Member whose Attending Physician has determincd the
Member's illness will result in a remaining life span of 6 months or less.
9.14.01
)
9.16 Major organ transplants at a facility deemed appropriate and authorized by AvMed, as well as
associated immunosuppressant medications ar~ covered except those deemed experimental. Coverage is
limited to the AvMed Choice Network. See Section 11.15.
9.16.01
Transportation benefits for transplant services are administered through Optum Health, an
AvMed third party partner. Benefits are limited to $200 per day up to $10,000 lifetime
maximum for a companion to accompany the Member (or two companions when the patient
is a minor) when the member has to travel greater than a 50 mile radius to receive the
transplant. This is a benefit available only when the transplant is authorized at one of
AvMed's contracted transplant facilities.
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9.17
Mammograms arc covered in accordance with Florida Statutes. One baseline mammogram is covered
for female Members between the ages of 35 and 39. A mammogram is available every two years for
female Members between the ages of 40 and 49 and a mammogram is available every year for female
Members aged 50 and older.
9.18
In addition, one or more mammograms a year are available when based upon a physician's
recommendation for any woman who is at risk for breast cancer because of a personal or
family history of breast cancer, because of having a history of biopsy-proven benign breast
disease, because of having a mother, sister, or daughter who has had breast cancer, or
because a woman has not given birth before the age of 30.
l\1astectomy surgery when performed for breast cancer. Coverage for post-mastectomy reconstructive
surgery shall include:
9.18.01 Reconstruction of the breast on which the mastectomy has been pcrformed;
9.18.02 Surgery and reconstruction on the other breast to produce a symmetrical appearance; and
9.17.01
Prostheses and physical complications during all stages of mastectomy including
Iymphedemas.
The length of stay will not be less than that determined by the Attending Physician to be
Medically Necessary in accordance with prevailing medical standards and after consultation
with the covered patient. The Attending Physician, after consultation with the covered
patient, may choose that the outpatient care be provided at the most medically appropriate
setting, which may include the hospital, treating physician's office, outpatient center, or
home of the covered patient.
Coverage is subject to any applicable Co-payment or Co-insurance and will require pre-
authorization of services as applicable to other surgical procedures or hospitalizations under
the Plan.
9.19 Newborn care. All services applicable for children under this Contract are covered for an enrolled
newborn child of the Subscriber or the enrolled newborn child ofa covered Dependent of the Snbscriber
or the newborn adopted child of the Subscriber (as described in Subsection 3.02.05), from the moment
of birth, including the Medically Necessary care or treatment of medically diagnosed congenital defects,
birth abnormalities or prematurity, and transportation costs to the nearest facility appropriately staffed
and equipped to treat the newborn's condition, when such transportation is Medically Necessary.
Circumcisions are provided for up to one year from date of birth.
9.18.03
9.18.04
9.18.05
9.20 Obstetrical and gynecological care. An annual gynecological examination and Medically Necessary
follow-up care detected at that visit are available without the need for a prior referral. Obstetrical care
benefits as specified herein are covered and include Hospital care, anesthesia, diagnostic imaging, and
laboratory services for conditions related to pregnancy unless such pregnancy is the result of a
preplanned adoption arrangement, more commonly known as surrogacy. The length of maternity stay in
a Hospital will be that determined to be Medically Necessary in compliance with Florida law and in
accordance with the Newborns' and Mothers' Health Protection Act, as follows:
9.20.01
Hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours
following a cesarean section;
The Attending Physician does not need to obtain authorization from AvMed to prescribe a
Hospital stay of this length;
AvMed will cover an extended stay, if Medically Necessary; however, your physician or
your Hospital must precertity the extended stay;
9.20.02
9.20.03
28
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MP-5320 (10/09)
9.20.04 Shorter Hospital stays are permitted if the attending health care provider, in consultation
with the mother, determines that to be the best course of action. Coverage for maternity care
is subject to applicable Co-payments and all other Plan limits and requirements.
Ortbotic appliances. Coverage for orthotic appliances is limited to custom-made leg, arm, back and
neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when
necessary to carry out normal activities of daily living, excluding sports activities. Coverage includes
the initial purchase, fitting or adjustment. Replacements are covered only when Medically Necessary
due to a change in bodily configuration. All other orthotic appliances are not covered. The deteonination
of whether a covered item will be paid under the DME, orthotics or prosthetics benefits will be based
npon its classification as defined by the Centers for Medicare and Medicaid Services. See Schedule of
Benefits for any Co-payments or Limitations. See Part XI for Exclusions.
Osteoporosis diagnosis and treatment when Medically Necessary for high-risk individuals, e.g.
estrogen-deficient individuals, individuals with vertebral abnormalities, individuals on long-term
glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism, and individnals with a
family history of osteoporosis.
Other Health Care Facility(ies). All routine services of Other Health Care Facilities (see Section
2.40), including physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered
for a maximum of 20 days per calendar year when a Member is admitted to such a facility, following
discharge from a Hospital, for a condition that cannot be adequately treated with Skilled Home Health
Care Services or on an ambulatory basis.
9.24 Outpatient therapeutic services. Covered health services for therapeutic treatments received on an
outpatient basis in your home, physician's office, Other Health Care Facility or Hospital, including
intravenous chemotherapy or other intravenous infusion therapy and Injectable Medications. Self-
Administered Injectable Medications are only a covered benefit when included in the supplemental
prescription medication benefits. See Section 11.29.
9.21
9.22
9.23
)
)
-}
9.25 Physician earc: inpatient. All Medical Services rendered by physicians and other Health Professionals
when requested or directed by the Attending Physician, including surgical procedures, anesthesia,
consultation and treatment by Specialty Health Care Physicians, laboratory and diagnostic imaging
services, and physical therapy (See Section 9.28) are covered while the Member is admitted to a
Participating Hospital as a registered bed patient. When available and requested by the Member, AvMed
covers the services of a certified nurse anesthetist licensed under Chapter 464, Florida Statutes.
9.26 Physician care: outpatient
9.26.01
9.26.02
Diagnosis and treatment. All Medical Services rendered by physicians and other Health
Professionals are covered when Medically Necessary and when provided at Medical Offices,
including surgical procedures, routine hearing examinations and vision examinations for
glasses for children under age 18 (such examinations may be provided by optometrists
licensed pursuant to Chapter 463, Florida Statutes or by ophthalmologists licensed pursuant
to Chapter 458 or 459, Florida Statutes) and consultation and treatment by Specialty Health
Care Physicians. Also included are non-reusable materials and surgical supplies. These
services and materials are subject to the Limitations outlined in Part X (Limitations of Basic
Benefits). See Part Xl for Exclusions.
Preventive and health maintenance services. The services of the Member's physician for
illness prevention and health maintenance, including child health supervision services and
immunizations provided in accordance with prevailing medical standards consistent with the
Recommendations for Preventive Pediatric Health Care of the American Academy of
Pediatrics and/or the Advisory Conunittee on hmnunization Practices; periodic health
assessment and physical examinations arc also covered. These services are subject to
29
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Limitations as outlined in Part X (Limitations of Basic Benefits). See Part XI for
Exclusions.
Hospital based providers who are considered Out-of-Network Providers because they do
not contract with AvMed or the PHCS Network, and who provide services in an outpatient
setting, will be paid at the mid-level.
9.27 Physical and occupational therapy. Short-term physical and occupational therapy provided in an
outpatient Of home care setting is covered to improve or restore physical functioning following disease,
injury or loss of a body part. Impairments, functional limitations and disabilities identified are
addressed by the design and implementation of a therapentic intervention tailored to the specific needs
of the individual patient. Physical and occupational therapy are covered when performed with the
expectation of restoring the patient's level of function which has been lost or reduced by injury or
illness. Therapy performed repetitively to maintain a level of function is not covered. Maintenance
begins when the therapeutic goals of a treatment plan have been achieved, or when no additional
functional progress is apparent or expected to occur. Coverage of outpatient physical and/or
occupational therapy is limited to a combined total 0130 visits per calendar year including evaluations.
Physical and occupational therapy are covered for the treatment of Autism Spectrum Disorder subject to
Section 9.07. See Schedule of Benefits for Co-payments/Co-insurance and Limitations.
9.26.03
t}
9.28 Prescription medication benefits. Allergy serums and chemotherapy for cancer patients arc covered.
Coverage for insulin and other diabetic supplies is described in Section 9.06 above. Other retail
prescription medications arc a covered benefit only when the Subscribing Group Contract includes
supplemental prescription medication benefits; coverage is subject to the Co-payment/Co-insurancc
provisions outlined therein.
Prosthetic devices. This Contract provides benefits, when Medically Necessary, for prosthetic devices
designed to restore bodily function or replace a physical portion of the body. Coverage for prosthetic
devices is limited to artificial limbs, artificial joints, ocular prostheses and cochlear implants. Coverage
includes the initial purchase, fitting, or adjustment. Replacement is covered only when Medically
Necessary due to a change in bodily configuration. The initial prosthetic device following a covered
mastectomy is also covered. Replacement of intraocular lenses is covered only if there is a change in
prescription that cannot be accommodated by eyeglasses. All other prosthetic devices are not covered
including prosthetic devices for Deluxe, Myo-electric and electronic prosthetic devices. The
determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits
will be based upon its classification as defined by the Centers for Medicare and Medicaid Services. See
Schedule of Benefits for any Co-payments or Limitations. See Part XI for Exclusions.
9.29
)
9.30 Second medical opinions. The Member is entitled to a second medical opinion when he disputes the
appropriat~ness or necessity of a surgical procedure or is subject to a serious injury or illness.
9.30.01
9.30.02
9.30.03
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MP-5320 (10/09)
The Member may obtain a second medical opinion from any participating or non-physician,
chosen by the Member. If a Participating Provider is chosen, there is no cost to the Member,
other than any applicable Co-insurance. If the Member chooses an Out-of-Network
Provider, the Member will be responsible for 40% of the amount of the Maximum Allowable
Payment for the second medical opinion.
Once a second medical opinion has been rendered, AvMed shall review and determine
AvMed's obligations under the Contract and that judgment is controlling. Any treatment the
Member obtains that is not authorized by AvMed shall be at the Member's expense.
AvMed may limit second medical opinions in connection with a particular diagnosis or
treatment to 3 per calendar year, if AvMed deems additional opinions to be an unreasonable
over-utilization by the Member.
30
)
9.31
Speech therapy. Speech therapy provided in the outpatient setting, including the home, is covered only
when existing speech function has been impaired by a disease or injury and there is a reasonable
expectation that improvement or restoration of speech function can be attained: Non-organic/functional
disorders, which are considered speech and language problems with no identifiable medical canse, are
not covered, except for the initial evaluation to determine the root cause. Coverage is limited to 24
visits per calendar year including evaluations. Speech therapy is covered for the treatment of Autism
Spectrum Disorder subject to Section 9.07. See Schednle of Benefits for Co-payments/Co-insurance
and Limitations.
')
9.32 Spinal manipulations will be covered only when Medically Necessary subject to Sections 2.36 and
2.60. No prior referral is required for these services.
9.33
Supplies. Ostomy, urostomy and wound care supplies are covered when Medically Necessary. Items
which are not medical supplies or which could be used by the Member or a family member for purposes
other than ostomy care are not covered. Wound care supplies are covered as part of an approved
treatment plan, when one of the following criteria is met:
- )
9.33.01
9.33.02
9.33.03
treatment of a wound caused by, or treated by, a surgical procedure; or
treatment of a wound that required debridement.
Provision of ostomy and urostomy supplies are limited to a one-month supply every 30 days.
Coverage is limited to $2,500 per Contract Year, subject to applicable Co-payments and Co-
Insurance.
9.34 Urgent Care services. All necessary and covered services received in Urgent Care or Immediate Care
Centers or rendered in your Primary Care Physician's office after-hours for conditions as described in
Section 2.57 will be covered by AvMed. See Schedule of Benefits for details. In addition, any Member
requests for reimbursement (of payment made by the Member for services rendered) must be filed
within 90 days after the emergency or as soon as reasonably possible but not later than one year unless
the Claimant was legally incapacitated.
9.35 Ventilator dependent care. With prior authorization by AvMed, ventilator dependent care (See Section
2.60) is covered up to a total of 100 days lifetime maximum benefit.
)
X. LIMITATIONS OF BASIC BENEFITS
The rights of Members and obligations of Participating Providers hereunder are subject to the following
Limitations:
10.0 I Cardiac rehabilitation. Coverage is limited to the number of visits or the dollar limit listed in the
Schedule of benefits, whichever is exhausted first.
10.02 Diagnosis and treatment of Autism Spectrum Disorder. Coverage for the diagnosis and treatment of
Autism Spectrum Disorder is limited to $36,000 annnally and may not excced $200,000 in total
benefits.
10.03 Home Health Care Services (SI<iUed Home Health Care). Services are limited to a period of2 hours
or less per visit, and 60 visits per calendar year.
10.04 Hyperbaric oxygen treatments are limited to 40 treatments per condition as appropriate pursuant to
the Centers for Medicare and Medicaid Services (CMS) guidelines, subject to applicable Co-payments
as listed for physical, speech and occupational therapies.
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10.05 Licenced dietitions/nutritionists. Visits to licensed dietitians/nutritionists for treatment of diabetes,
renal disease or obesity control shall be limited to 3 outpatient visits per calendar year and each visit
requires a Co-payment. See Schedule of Benefits and Section 11.17.
10.06 Major Organ Transplants - transportation services. Transportation benefits for transplant services
are administered through Optum Health, an AvMed third party partner. Benefits are limited to $200 per
day up to $10,000 lifetime maximum for a companion to accompany the Member (or two companions
when the patient is a minor) when the member has to travel greater than a 50 mile radius to receive the
transplant. This is a benefit available only when the transplant is authorized at one of AvMed's
transplant contracted facilities.
10.07 Orthotic appliances. Coverage for orthotic appliances is limited to custom-made leg, arm, back and
neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when
necessary to carry out nonnal activities of daily living, excluding sports activities.
10.08 Other Health Care Facility(ies). All routine inpatient services of other health care facilities (See
Section 2.40), including physician visits, physiotherapy, diagnostic imaging and laboratory work, are
covered for a maximum of 20 days per calendar year when a Member is admitted to such a facility,
following discharge from a Hospital, for a condition that cannot be adequately treated with Home
Health Care Services or on an ambulatory basis.
10.09 Physical and occupational therapy. Physical and occupational therapies shall be limited as explained
in Section 9.27.
10.10 Prosthetic devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, ocular
prostheses and cochlear implants.
10.11 Second medical opinions. AvMed may limit second medical opinions in connection with a particular
diagnosis or treatment to three per calendar year, if AvMed deems additional opinions to be an
\ unreasonable over-utilization by the Member.
10.12 Speech therapy. Coverage is limited to 24 visits per calendar year including evaluations.
10.13 Substance abuse--Hospital Limitation. Inpatient services for alcohol and drug abuse shall be provided
but only for acute detoxification and the treatment of other medical sequelae of such abuse. Inpatient
alcohol or drug rehabilitation services are not covered.
10.14 Supplies. Provision of ostomy, urostomy and wound care supplies are limited to a one-month supply
every 30 days. Coverage is limitcd to $2,500 per Contract Year, subject to applicable Co-payments and
Co-Insurance.
10.15 Ventilator dependent care. The total benefit for ventilator dependent care is limited to 100 calendar
days lifetime maximum.
XI. EXCLUSIONS FROM BASIC BENEFITS
Medical Services and benefits for the following classifications and conditions are not covered and are excluded
from the Schedule of Basic Benefits provided under this Contract:
11.01 Aids or devices that assist with nonverbal communications, including but not limited to
communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal
Digital Assistants (I'D As) Braille typewriters, visual alcrt systems for the deaf and memory books.
11.02 Armed forces service-connected medical care for both sickness and injury.
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11.03 Autopsy or postmortem examinations and associated services, including the autopsy.
11.04 Breast reduction or augmentation. Surgery for the reduction or augmentation of the size of the breasts
except as required for the comprehensive treatment of breast cancer.
11.05 Complementary or alternative medicine including, but not limited to, self-care or self-help training;
homeopathic medicine and counseling; Ayurvedic medicine such as lifestyle modifications and
purification therapies; traditional Oriental medicine including acupuncture; naturopathic medicine;
environmental medicine including the field of clinical ecology; chelation therapy; therrnography; mind-
body interactions such as meditation, imagery, yoga, dance, and art therapy; biofeedback; hypnotherapy;
prayer and mental healing; manual healing methods snch as the Alexander technique, aromatherapy,
massage therapy including but not limited to: Ayurvedic massage, craniosacral balancing, Feldenkrais
method, Hellerwork, reflexology, rolling, shiatsu, traditional Chinese massage, Trager therapy, trigger-
point myotherapy, and polarity therapy. Reichian therapy, biofield therapeutics; Reiki, SHEN therapy,
and therapeutic touch; bioelectromagnetic applications in medicine; herbal therapies; sleep therapy, sex
therapy, behavioral training, cognitive therapy, and vocational rehabilitation.
11.06 Complications of any non-covered service, including the evaluation or treatment of any condition that
arises as a complication of a non-covered service.
11.07 Cosmetic, surgical or non-surgical procedures which are undertaken primarily to improve or
otherwise modify the Member's external appearance arc excluded, except for reconstructive surgery to
correct and repair a functional disorder as a result of a disease, injury. or congenital defect or initial
implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast. Also
excluded are surgical excision or reformation of any sagging skin of any part of the body, including, but
not limited to: the eyelids, face, neck, abdomen, arms, legs, or buttocks; any services performed in
connection with the enlargement, reduction, implantation or change in appearance of a portion of the
body, including, but not limited to: the face, lips, jaw, chin, nose, ears, breasts, or genitals (inclnding
circumcision, except newborns for up to one year from date of birth; see also Section 10.18); hair
transplantation, chemical face peels or abrasion of the skin, electrolysis depilation, removal of tattooing;
or any other surgical or non-surgical procedures which are primarily for cosmetic purposes or to create
body symmetry. Additionally, all medical complications as a result of cosmetic, surgical or non-surgical
procedures are excluded.
11.08 Cosmetics, dietary supplements, nutritional formulae, health or beauty aids.
11.09 Custodial Care as defined in Section 2.16.
11.10 Dental Care, as defined in Section 2.17, for any condition except:
11.1 0.01 Services, supplies or appliances for Dental Care necessary to promptly repair (but not
replace), sound natural teeth required as a result of and directly related to an accidental
injury sustained while covered under the Plan. Treatment must begin 90 days from date of
injury. Such services are limited to $1,000 per calendar year;
11.10.02 Reconstructive jaw surgery for the treatment of deforrnities that are present and apparent at
birth; or
11.1 0.03 Services for the treatment of tumors or full mouth extraction when required before radiation
therapy.
11.10.04 Treatment must be completed within nine months from date of injury.
11.11 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities,
behavioral problems and developmental delays. Expenses for remedial or special education, counseling,
or therapy including evaluation and treatment of the above-listed conditions or behavioral training
whether or not associated with manifest mental disorders or other disturbances.
)
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11.12 Durable Medical Equipment (DME) non-covered include (but are not limited to) the following:
11.12.0 I Bed Related Items: bed trays, over the bed tables, bed wedges, pillows, cnstom bedroom
equipment, mattresses, including non-power mattresses, custom mattresses and posturepedic
mattresses;
11.12.02 Bath Related Items: bath lifts, non-portable whirlpools, bathtub rails, toilet rails, raised toilet
seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, and spas;
11.12.03 Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about
chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts
(mechanical or motorized - mannal hydraulic lifts are covered if patient is two-person
transfer), and auto tilt chairs;
11.12.04 Fixtures to Real Property: ceiling lifts and wheelchair ramps;
11.12.05 CarNan Modifications;
11.12.06 Air Quality Items: room humidifiers, vaporizers, air purifiers and electrostatic machines;
11.12.07 BloodlInjection Related items: blood pressure cuffs, centrifuges, nova pens and needle less
injectors; and
11.12.08 Other Equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic-
controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
board, AC/DC adaptors, enuresis alanns, magnetic equipment, scales (baby and adult), stair
gliders, elevators, saunas, any exercise equipment and diathermy machines.
11.13 Emergency room services for non-emergency purposes. See Sections 2.19 and 2.20.
11.14 Exercise programs, gym memberships, or exercise equipment of any kind, including, but not limited
to: exercise bicycles, treadmills, stairmasters, rowing machines, free weights or resistance equipment.
Also excluded are massage devices, portable whirlpool pumps, hot tubs, jacuzzis, sauna baths,
swimming pools and similar equipment.
11.15 Experimental and/or investigational procedures, except for bone marrow transplants, as approved per
Florida Administrative Code, Section 59B-12.001. For the purposes of this Contract, a medication,
treatment, device, surgery or procedure may be determined to be experimental and/or investigational if
any of the following applies:
11.15.01 The FDA has not granted the approval for general use;
11.15.02 There are insufficient outcomes data available from controlled clinical trials published in
peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury
involved;
11.15.03 There is no consensus among practicing physicians that the medication, treatment, therapy,
procedure or device is safe or effective for the treatment in question or such medication,
treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or
device utilized by practicing physicians in treating other patients with the same or a similar
condition; or
11.15.04 Such medication, treatment, procedure or device is the subject of an ongoing Phase I or
Phase II clinical investigation, or experimental or research arm of a Phase III clinical
investigation, or under study to determine: maximum tolerated dosages, toxicity, safety,
efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the
condition in question.
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11.16 Eye care including:
11.16.01 Eye examinations for Members 18 years of age or older for the purpose of detennining the
need for sight correction (such as eye glasses or contact lenses);
)
Training or orthoptics, including eye exercises; or
Radial keratotomy, refractory keratoplasty, Lasik surgery or any other corneal surgical
procedure to correct refractive error.
11.17 Foot supports are not covered. These include orthopedic or specialty shoes, shoe build-ups, shoe
orthotics, shoe braces, and shoe supports. Also excluded is routine foot care, including trimming of
corns, calluses, and nails.
11.16.02
11.16.03
11.18 Gastric stapling, gastric bypass, gastric banding, gastric bnbbles, and other procedures for the
treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests. Ongoing
visits other than establishing a program of obesity control.
11.19 Gender reassignment surgery as well as any service, supply, or medical care associated with gender
reassigmnent or gender identity disorders.
11.20 Home monitoring devices and measuring devices (other than apnea monitors), and any other
equipment or devices for use outside the Hospital.
11.21 IIospital Scrvices that are associated with excluded surgery or Dental Care.
11.22 Hearing examinations for Members 18 years of age or older for the purpose of determining the need
for hearing correction.
11.23 Infertility diagnosis, treatment, and supplies, including infertility testing, treatment of infertility,
diagnostic procedures and artificial insemination, to determine or correct the cause or reason for
infertility or inability to achieve conception. This includes artificial insemination, in-vitro fertilization,
ovum or embryo placement or transfer, gamete intra-fallopian tube transfer, or cryogenic or other
preservation techniques used in such or similar procedures. Also excluded are obstetrical benefits when
such pregnancy is the subject of a preplalmed adoption arrangement, or surrogacy, as defined under
Chapter 63, Florida Statutes. Medications for the treatment of infertility are not covered.
11.24 Immunizations and medications for the purpose of foreign travel or employment.
11.25 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions caused
by congenital or developmental deformity, disease, or injury.
11.26 Medical care or surgery not authorized by a Participating Provider, except for Emergency Medical
Services and Care, or not within the benefits covered by AvMed.
11.27 Medical supplies including, but not limited to: pre-fabricated splints, Thromboemboletic/Support hose
and all other bandages, except as provided in Section 9.33.
11.28 Organ donor treatmeut aud services. The Medical Services and Hospital Services for a donor or
prospective donor who is an AvMed Member when the recipient of an organ transplant is not an AvMed
Member. Coverage is provided for costs associated with the bone marrow donor-patients to the same
extent as the insured recipient. The reasonable costs of searching for the bone marrow donor is limited
to family members and the National Bone Marrow Donor Program. Post-transplaut donor
complications will not be covered.
11.29 Over-the-counter medications, and prescription medications not otherwise covered including all
contraceptives (medications and devices), hypodermic necdles and syringes and Self-Administered
Injectable Medications except insulin and insulin syringes for the treatment of diabetes as outlined in
Section 9.06.
-)
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) 11.30 Personal comfort items not Medically Necessary for proper medical care as Part of the therapeutic plan
to treat or arrest the progression of an illness or injury. This Exclusion includes, but is not limited to:
wigs (including partial hair pieces, weaves, and toupees), personal care kits, guest meals and
acconunodations, maid services, televisions/radios, telephone charges, photographs, complimentary
meals, birth announcements, take home snpplies, travel expenses (other than Medically Necessary
ambulance services that are provided for in Section 9.01), air conditioners, humidifiers, dehumidifiers,
and air purifiers or filters.
11.31 Physical examinations or tests, such as premarital blood tests or tests for continuing employment,
education, licensing, or insurance or that are otherwise required by a third party.
11.32 Physical, speech, occupational, and all otber therapies for chronic conditions. Maintenance therapy
is not covered. Maintenance therapy begins when the therapeutic goals of a treatment plan have been
met and/or no further functional progress is expected. Speech therapy for non-organic or functional
disorders is not covered, except for the initial evaluation to determine the root cause. Examples include
attention deficit disorder, developmental delay, mental retardation; and Down's syndrome. Abnonnal
speech pathology, including but not limited to lisping and stuttering, is not covered.
Private duty nursing services.
Rehabilitation programs. Alcohol or substance abuse rehabilitation, vocational rehabilitation,
pulmonary rehabilitation, long tenn rehabilitation, or any other rehabilitation program.
Removal of benign skin lesions and warts, moles, skin tags, lipomas, keloids, and scars is not covered,
even with a recommendation or prescription by a physician.
Reversal of sterilization procedures.
Sexual dysfunction. All medications, devices, and other forms of treatment related to a diagnosis of
sexual dysfunction, regardless of etiology.
Smoking cessation. Any service or supply to eliminate or reduce dependency on or addiction to
tobacco, including but not limited to: nicotine withdrawal programs, facilities, and supplies (e.g.
transdermal patches, Nicoretle gum).
11.39 Speech therapy for delayed or abnormal speech pathology.
11.40 Substance abuse treatment. Treatment for chronic alcoholism and chronic drug addiction, except those
services offered as a basic health service. See Section 10.13.
0
11.33
11.34
11.35
11.36
11.37
)
11.38
11.41 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and vascular grafts Dental
appliances, other corrective lenses and hearing aids, including the professional fee for fitting them, are
not covered.
11.42 Temporomandibular Joint Dysfunction (TMJ). Services related to the diagnosis/treatment of TMJ
except when Medically Necessary; all dental treatment for TMJ.
11.43 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to
applicable State and Federal laws or as specified in the Elective Tennination of Pregnancy amendment
to the Subscribing Group Contract.
11.44 Travel expenses including expenses for ambulance services to and from a physician or Hospital except
in accordance with Section 9.01. Ambulance services are not covered when the skill of medically
trained personnel is not required and the Member can be safely transported by other means.
11.45 Treatment of a condition resulting from:
11.45.01 Participation in a riot or rebellion;
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11.45.02 Engagement in an illegal occupation;
11.45.03 Your participation in, or cOlnrnission of, any act punishable by law as a felony whether or
not you are charged or convicted.
11.46 Ventilator dependent care, except as provided in Part X (Schcdule of Basic Benefits) for 100 days
lifetime maximum benefit.
11.47 Workers' Compensation benefits. Any sickness or injury for which the covered person is paid
benefits, or may be paid benefits if claimed, if the covered person is covered or required to be covered
by Workers' Compensation. In addition, if the covered person enters into a settlement giving up rights
to recover past or future medical benefits under a Workers' Compensation law, AvMed shall not cover
past or future Medical Services that are the subject of or related to that settlement. Furthermore, if thc
covered person is covered by a Worker's Compensation program that limits benefits if other than
specified health care providers arc used and the covered person receives care or services from a health
care provider not specified by the program, AvMed shall not cover the balance of any costs remaining
after the program has paid.
')
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XII. COORDINATION OF BENEFITS
12.01 The services and benefits provided under this Contract are not intended to and do not duplicate any
benefit to which Members are entitled under any other Group Hcalth Insurance, HMO, personal injury
protection and medical payments under the automobile insurance laws of this or any other jurisdiction,
governmental organization, agency, or any other entity providing health or accident benefits to a
Member, including but not limited to: Medicare, Worker's Compensation, Pnblic Health Servicc,
Champus, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or law. -
AvMcd coverage will be primary to Medicaid and Children's Health Insurance Program (CHIP)
benefits.
)
12.02 If any covered person is eligible for services or benefits under two or more plans as set forth in Section
12.0 I, the coverage under those plans will be coordinated so that up to but not more than 100% of any
eligiblc expense will be paid for or provided by all such plans combined. The Member shall execnte
and deliver such instruments and papers as may be required and do whatever else is necessary to secure
such rights to AvMed. Failure to do so will result in nonpaymcnt of Claims. Requested information
should be provided to AvMed within 30 days of request or Member will be responsible for payment of
the Claim. Information received after one year from date of service will not be considered.
12.03 The standards governing the coordination of benefits are the following, pursuant to the provisions of
Section 627.4235, Florida Statutes:
12.03.01 The benefits of a policy or plan that covers the person as an employee, member, or
subscriber, other than as a dependent, are determined before those of the policy or plan
which covers the person as a dependent.
12.03.02 Except as stated in Subsection 12.03.03, when two or more policies or plans cover the same
child as a dependent of different parents:
a) The benefits of the policy or plan of the parent whose birthday, excluding year of birth,
falls earlier in a year are detennined before the benefits of the policy or plan of the
parent whose birthday, excluding year of birth, falls later in the year; but
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b) If both parents have the same birthday, the benefits of the policy or plan which covered
the parent for a longer period of time are determined before those of the policy or plan
which covered the parent for a shorter period of time.
c) However, if a policy or plan subject to the rule based on the birthday of the parents as
stated above coordinates with an out-of-state policy or plan which contains provisions
under which the benefits of a policy or plan which covers a person as a dependent of a
male are determined before those of a policy or plan which covcrs the person as a
dependent of a female and if, as a result, the policies or plans do not agree on the order
of benefits, the provisions of the other policy or plan shall determine the order of
benefits.
12.03.03 If two or more policies or plans cover a dependent child of divorced or separated parents,
benefits for the child are determined in this order:
a) First, the policy or plan of the parent with custody of the child;
b) Second, the policy or plan of the spouse of the parent with custody of the child; and
c) Third, the policy or plan of the parent not having custody of the child.
d) However, if the specific terms of a court order state that one of the parents is
responsible for the health care expenses of the child and if the entity obliged to payor
provide the benefits of the policy or plan of that parent has actual knowledge of those
terms, the benefits of that policy or plan are determined first. This does not apply with
respect to any claim determination period or plan or policy year during which any
benefits are actually paid or provided before that entity has that actual knowledge.
12.03.04 The benefits of a policy or plan which covers a pcrson as an employee who is neither laid off
nor retired, or as that employee's dependent, arc determined before those of a policy or plan
which covers that person as a laid off or retired employee or as that employee's dependent.
If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans
do not agree on the order of benefits, this Subsection shall not apply.
12.03.05 If none of the rules in Subsections 12.03.01, 12.03.02, 12.03.03, or 12.03.04 determine the
order of benefits, the benefits of the policy or plan which covered an employee, member, or
subscriber for a longer period of time are determined before those of thc policy or plan
which covered that person for the shorter period of time.
12.03.06 Coordination of benefits shall not be permitted against an indemnity-type policy, an excess
insurance policy as defincd in Section 627.635, Florida Statutes, a policy with coverage
limited to specified illnesses or accidents, or a Medicare supplement policy. However, if the
person is also a Medicare beneficiary, and if the rule established under the Social Security
Act of 1965, as amended, makes Medicarc secondary to the plan covering the person as a
dependent cfan active employee, the order of benefit determination is;
a) First, benefits of a plan covering a person as an employee, member, or subscriber.
b) Second, benefits ofa plan of an active worker covering a person as a dependent.
c) Third, Medicare benefits.
12.03.07 Ifan individual is covered under a COBRA continuation plan as a result of the purchase of
coverage as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987
(Pub.1.. No. 99-272), and also under another Group Hcalth Insurance plan, the following
order of benefits applies:
a) First, the plan covering the person as an employee or as the employee's dependent.
)
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b) Second, the coverage purchased nnder the plan covering the person as a fanner
employee, or as the former employee's dependent provided according to the provisions
of COBRA.
)
12.04 For the purpose of determining the applicability and implementing the terms of the Coordination of
Benefits provision of this Contract, AvMed may, without the consent of or notice to any person, release
to or obtain fronl any other insurance company, organizations or person, any infonnation, with respect
to any Subscriber or applicant for subscription, which AvMed deems to be necessary for such purposes.
12.05 Whenever payments which should have been made under this Plan in accordance with this provision
have been made under any other plans, AvMed shall have the right, exercisable alone and in its sole
discretion, to pay over to any organizations making such other payments any amounts AvMed shall
determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be
deemed to be benefits paid nnder this Plan.
12.06 All treatments must be Medically Necessary and comply with all terms, conditions, Limitations, and
Exclusions of this Plan even if AvMed is secondary to other coverage and the treatment is covered under
the other coverage.
12.07 If the amount of the payments made by AvMed is more than it should have paid under the provisions of
this Part XII, it may recover the excess from one or more of the persons it has paid or for whom it has
paid; or any other person or organization that may be responsible for the benefits or services provided
for the Member. The 'amount of the payments made' includes the reasonable cash value of any benefits
provided in the fonn of services.
12.08 In the event the Subscribing Group offers Health Reimbursement Arrangements (HRA) in connection
with this Plan, the HRA is intended to pay solely for otherwise un-reimbursed medical expenses.
Accordingly, it shall not be considered a group health plan for coordination of benefits purposes, and its
benefits shall not be taken into account when detennining benefits payable under any other plan.
-)
)
XIII. SUBROGATION AND RIGHT OF RECOVERY
If AvMed provides health care benefits under this Contract to a Member for injuries or illness for which another
party is or may be responsible, then AvMed retains the right to repayment of the full cost of all benefits provided
by AvMed on behalf of the Member that are associated with the injury or illness for which another party is or
may be responsible. AvMed's rights of recovery apply to any recoveries made by or on behalf of the Member
from the following third-party sources, as allowed by law, including but not limited to: payments made by a
third-party tortfeasor or any insurance company on behalf of the third-party tort feasor; any payments or awards
under an uninsured or underinsured motorist coverage policy; any worker's compensation or disability award or
settlement; medical payments coverage under any automobile policy, premises or homeowners medical
payments coverage or premises or homeowners insurance coverage; any other payments from a source intended
to compensate a Member for injuries resulting from an accident or alleged negligence. For purposes of this
Contract, a tortfeasor is any party who has committed injury, or wrongful act done willingly, negligently or in
circumstances involving strict liability, but not including breach of contract for which a civil suit can be brought.
Member specifically acknowledges AvMed's right of subrogation. When AvMed provides health care benefits
for injuries or illnesses for which a third party is or may be responsible, AvMed shall be subrogated to the
Member's rights of recovery against any party to the extent of the full cost of all benefits provided by AvMed, to
the fullest extent permitted by law. AvMed may proceed against any party with or without the Member's
consent.
)
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) Member also specifically acknowledges AvMed's right of reimbursement. This right ofreimbursement attaches,
to the fullest extent permitted by law, when AvMed has provided health care benefits for injuries or illness for
which another party is or may be responsible and the Member and/or the Member's representative has recovered
any amounts from the third party or any party making payments on the third party's behalf. By providing any
benefit under this Contract, AvMed is granted an assignment of the proceeds of any settlement, judgment or
other payment received by the Member to the extent of the full cost of all benefits provided by AvMed.
AvMed's right of reimbursement is cumulative with and not exclusive of AvMed's subrogation right and AvMed
may choose to exercise either or both rights of recovery.
Member and the Member's representatives further agree to:
13.01 NotifY AvMed promptly and in writing when notice is given to any third party of the intention to
investigate or pursue a claim to recover damages or obtain compensation due to injuries or illness
sustained by the Member that may be the legal responsibility of a third party; and
13.02 Cooperate with AvMed and do whatever is necessary to secure AvMed's rights of subrogation and/or
reimbursement under this Contract; and
13.03 Give AvMed a first-priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third party to the extent of the full cost of all benefits associated
with injuries or illness provided by AvMed for which a third party is or may be responsible (regardless
of whether specifically set forth in the recovery, settlement, judgment or compensation agreement); and
13.04 Pay, as the first priority, from any recovery, settlement or judgment or other source of compensation,
any and all amounts due AvMed as reimbursement for the full cost of all benefits associated with
injuries or illness provided by AvMed for which a third party is or may be responsible (regardless of
whether specifically set forth in the recovery, settlement, judgment, or compensation agreement), unless
otherwise agreed to by AvMed in writing; and
13.05 Do nothing to prejudice AvMed's rights as set forth above. This includes, but is not limited to,
refraining from making any settlement or recovery, which specifically attempts to reduce or exclude the
full cost of all benefits, provided by AvMed.
)
AvMed may recover the full cost of all benefits provided by AvMed under this Contract without regard to any
claim of fault on the part of the Member, whether by comparative negligence or otherwise. No court costs or
attorney fees may be deducted from AvMed's recovery without the prior express written consent of AvMed. In
the event the Member or the Member's representative fails to cooperate with AvMed, the Member shall be
responsible for all benefits paid by AvMed in addition to costs and attorney's fees incurred by AvMed in
obtaining repayment.
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XIV. DISCLAIMER OF LIABILITY
)
14.01 Neither Subscribing Group nor its agents, servants or employees, nor any Member is the agent or
representative of AvMed, and none of them shall be liable for any acts or omissions of AvMed, its
agents or employees or of a Participating Hospital, or a Participating Physician, or any other person or
organization with which AvMed has made or hereafter shall make arrangements for the performance of
services under this Contract.
14.02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to AvMed or
Participating Providers except as specifically set forth herein, provided all procedures set forth herein
are followed.
14.03 Neither AvMed nor its agents, servants or employees, nor any Member is the agent or representative of
the Subscribing Group, and none of them shall be liable for any acts or omissions of Subscribing Group,
its agents or employees or any other person representing or acting on behalf of Subscribing Group.
14.04 AvMed does not directly employ any practicing physicians nor any Hospital personnel or physicians.
These health care providers are independent contractors and are not the agents or employees of AvMed.
AvMed shall be deemed not to be a health care provider with respect to any services performed or
rendered by any such independent contractors. Participating Providers maintain the physician/patient
relationship with Members and are solely rcsponsible for all Medical Services which Participating
Providers render to Members. Therefore, AvMed shall not be liable for any negligent act or omission
committed by any independent practicing physicians, nurses, or medical personnel, nor any Hospital or
health care facility, its personnel, other health care professionals or any of their employees or agents
who may, from time to time, provide Medical Services to a Member of AvMed. Furthermore, AvMed
shall not be vicariously liable for any negligent act or omission of any of these independent health care
professionals who treat a Member of AvMed.
14.05 Certain Members may, for personal reasons, refuse to accept procedures or treatment recommended by
Participating Physicians. Participating Physicians may regard such refusal to accept their
recommendations as incompatible with the continuance of the physician/patient relationship and as
obstructing the provision of proper medical care. If a Member refuses to accept the medical treatment
or procedure recommended by the Participating Physician and if, in the judgment of the Participating
Physician, no professionally acceptable altemative exists or if an alternative treatment does exist but is
not recommended by the Participating Physician, the Member shall be so advised.
14.06 If the Member continues to refuse the recommended treatment or procedure, AvMed may terminate the
Member's coverage under this Contract as set forth in Part Vlll, Subsection 8.01.05.
~)
)
XV. GRIEVANCE I'ROCEDJ)RE
A grievance is any complaint other than one that involves a request (Claim) for benefits or an appeal as
described in Section 15.02 below. Members have the right to a review of any complaint rcgarding the services
or benefits covered under this Plan. AvMed encourages the infoTInal resolution of complaints. If you have a
complaint, you or someone you name to act on your behalf (your authorized representative) may call AvMed's
Member Services Department, and a Member Services Representative will try to resolve your complaint for you
ovcr the phone. If you ask for a written response, or if the complaint is related to quality of care, A vMed will
respond to you in writing. The Member Services Department can also tell you how to name your authorized
representative. Ifa Member's complaint cannot be resolved informally (over the telephone), the c9mplaint may
be submitted to AvMed in writing, through the formal grievance process. The proccdures for filing a grievance
are described in 15.01, below.
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) If a Member has a complaint involving a Claim for benefits, including a benefit denial, he or she may file a
written appeal with AvMed. The procedures for filing an appeal are described below, beginning with Section
15.02.02.
15.01 Grievances relating to plan services:
15.01.01 If a Member's complaint cannot be resolved informally over the telephone, the complaint
may be submitted in writing to AvMed's Member Services Department. We call this 'filing a
grievance', Grievances must be filed within one year of the occurrence of the event or action
that led to the grievance. We will acknowledge and investigate the grievance, and provide a
written response advising of the disposition of the grievance within 60 days after receipt of
the written grievance. You may submit a grievance in writing to:
f)
AvMed Member Services - North
P.O. Box 823
Gainesville, Florida 32602-0823
Telephone: 1-800-882-8633
Fax: (352) 337-8612
AvMed Member Services - South
P.O. Box 569008
Miami, Florida 33156-9906
Telephone: 1-800-882-8633
Fax: (305) 671-4736
15.01.02 If you are not satisfied with AvMed's final decision, you may contact the Agency for Health
Care Administration (AHCA) or the Department of Financial Services (DFS) in writing
within 365 days of receipt of AvMed's final decision letter. If you appeal AvMed's decision,
your grievance will be reviewed by the Subscriber Assistance Program. You also have the
right to contact AHCA or DFS at any time to inform them of an ul11esolved grievance.
a)
The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. If you need further assistance, you may contact:
)
Subscriber Assistance Program (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1-800-342-2762
15.02 Pre-Service Claims.
15.02.01 Initial Claim. A Pre-Service Claim shall be deemed to be filed on the date received by
AvMed. AvMed shall notify the Claimant of the benefit determination (whether adverse or
not) within a reasonable period of time appropriate to the medical circumstances, but not
later than 15 days after AvMed receives thc Pre-Service Claim. AvMed may extend this
period one time for up to 15 days, provided that AvMed determines that such an extension is
necessary due to matters beyond AvMed's control and notifies the Claimant, before the
expiration of the initial 15-day period, of the circumstances requiring the extension of time
and the date by which AvMed expects to render a decision. If such an extension is necessary
because the Claimant failed to submit the information necessary to decide the Claim, the
notice of extension shall specifically describe the required information, and the Claimant
shall be afforded at least 45 days from receipt of the notice within which to provide the
specified information. In the case of a failure by a Claimant to follow AvMed's procedures
for filing a Pre-Service Claim, the Claimant shall be notified of the failure and the proper
procedures to be followed in filing a Claim for benefits not later than five days following
such failure. AvMed's period for making the benefit detennination shall be tolled from the
J
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date on which the notification of the extension is sent to the Claimant until the date on which
the Claimant responds to the request for additional infonnation. If the Claimant fails to
supply the requested information within the 45-day period, the Claim shall be denied.
15.02.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Pre-
Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed
shall notify the Claimant, in accordance with Section 15.08, of its determination on review
within a reasonable period of time. Such notification shall be provided not later than 30
days after AvMed receives the Claimant's request for review of the Adverse Benefit
Determination. You may submit an appeal to:
AvMed Member Services - North
P.O. Box 823
Gainesville, Florida 32602-0823
Telephone: 1-800-882-8633
Fax: (352) 337-8612
)
AvMed Member Services - South
P.O. Box 569008
Miami, Florida 33156-9906
Telephone: 1-800-882-8633
Fax: (305) 671-4736
- )
15.02.03 If you are not satisfied with AvMed's final decision, you may contact AHCA or DFS in
writing within 365 days of receipt of the final decision letter. If you appeal AvMed's
decision, your grievance will be reviewed by the Subscriber Assistance Program. You also
have the right to contact AHCA or DFS at any time to infornl them of an ul11esolved
grievance.
a) The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. Uyau need further assistance, you may contact:
Subscriber Assistance Program (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1-800-342-2762
)
15.03 Post-Service Claims.
15.03.01 Initial Claim. A Post-Service Claim shall be deemed to be filed on the date received by
AvMed. AvMed shall notify the Claimant, in accordance with Section 15.06 of AvMed's
Adverse Benefit Determination within a reasonable period of time, but not later than 30 days
after AvMed receives the Post-Service Claim. AvMed may extend this period one time for up
to 15 days, provided that AvMed detennines that such an extension is necessary due to
matters beyond AvMed's control and notifies the Claimant, before the expiration of the
initial 30-day period, of the circumstances requiring the extension of time and the date by
which AvMed expects to render a decision. If such an extension is necessary because the
Claimant failed to submit the information necessary to decide the Post-Service Claim, the
notice of extension shall specifically describe the required infonnation, and the Claimant
shall be afforded at least 45 days from receipt of the notice within which to provide the
specified information. AvMed's period for making the benefit determination shall be tolled
from the date on which the notification of the extension is sent to the Claimant until the date
on which the Claimant responds to the request for additional information. If the Claimant
fails to supply the requested infonnation within the 45-day period, the Claim shall be denied.
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)
15.03.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Post-
Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed
shall notify the Claimant, in accordance with Section 15.08, of AvMed's determination on
review within a reasonable period of time. Such notification shall be provided not later than
60 days after AvMed receives the Claimant's request for review of the Adverse Benefit
Determination. You may submit an appeal to:
AvMed Member Services - North AvMed Member Services - South
P.O. Box 823 P.O. Box 569008
Gainesville, Florida 32602-0823 Miami, Florida 33156-9906
Telephone: 1-800-882-8633 Telephone: 1-800-882-8633
Fax: (352) 337-8612 Fax: (305) 671-4736
15.03.03 If you are not satisfied with AvMed's final decision, you may contact AHCA or DFS in
writing within 365 days of receipt of the final decision letter. If you appeal AvMed's
decision, your grievance will be reviewed by the Subscriber Assistance Program. You also
have the right to contact AI-ICA or DFS at any time to inform them of an unresolved
grievance.
a) The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. Uyau need further assistance, you may contact:
t)
)
Subscriber Assistance Program (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1-800-342-2762
I )
15.04 Urgent Care Claims.
15.04.01 Initial Claim. An Urgent Care Claim sh~lI be deemed to be filed on the date received by
AvMed. AvMed shall notify the Claimant of AvMed's benefit determination (whether
adverse or not) as soon as possible, taking into account the medical exigencies, but not later
than 72 hours after AvMed. receives, either orally or in writing, the Urgent Care Claim,
unless the Claimant fails to provide sufficient information to determine whether, or to what
extent, benefits are covered or payable under the Plan. If such information is not provided,
AvMed shall notify the Claimant as soon as possible, but not later than 24 hours after AvMed
receives the Claim, of the specific information necessary to complete the Claim. The
Claimant shall be afforded a reasonable amount of time, taking into account the
circumstances, but not less than 48 hours, to provide the specified information. AvMed shall
notify the Claimant of the benefit determination as soon as possible, but in no case later than
48 hours after the earlier of:
a) AvMed's receipt of the specified infornlation; or
b) The end of the period afforded the Claimant to provide the specified additional
information.
15.04.02 If the Claimant fails to supply the requested information within the 48-hour period, the
Claim shall be denied. AvMed may notify the Claimant of the benefit determination orally or
in writing. If the notification is provided orally, a written or electronic notification, meeting
44
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)
the requirements of Section 15.06, shall be provided to the Claimant no later than three days
after the oral notification.
')
15.04.03 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent
Care Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall
notify the Claimant, in accordance with Section 15.08, of AvMed's benefit determination on
review as soon as possible, taking into account the medical exigencies, but not later than 72
hours after AvMed receives the Claimant's request for review of an Adverse Benefit
Determination. You may submit an appeal to:
AvMed Member Services - North AvMed Member Services - South
P.O. Box 823 P.O. Box 569008
Gainesville, Florida 32602-0823 Miami, Florida 33156-9906
Telephone: 1-800-882-8633 Telephone: 1-800-882-8633
Fax: (352) 337-8612 Fax: (305) 671-4736
15.04.04 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for
Health Care Administration (AHCA) or the Department of Financial Services (DFS) in
writing within 365 days of receipt of the final decision letter. If you appeal AvMed's
decision, your grievance will be reviewed by the Subscriber Assistance Program. You also
have the right to contact the AHCA or DFS at any time to inform them of an ul11esolved
grievance.
-j
a) The Subscriber Assistance Program will not hear a grievance if you have not completed
the entire AvMed grievance process nor if you have instituted an action pending in State
or Federal court. If you need further assistance, you may contact:
Subscriber Assistance Program (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1-888-419-3456, or
850-921-5458
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1-800-342-2762
)
15.05 Concurrent Care Claims
15.05.01 Any reduction or termination by AvMed of Concurrent Care (other than by Plan amendment
or termination) before the end of an approved period of time or number of treatments, shall
constitute an Adverse Benefit Determination. AvMed shall notify the Claimant, in
accordance with Section 15.06, of the Adverse Benefit Determination at a time sufficiently
in advance of the reduction or termination to allow the Claimant to appeal and obtain a
detennination on review of the Adverse Benefit Determination before the benefit is reduced
or terminated.
15.05.02 Any request by a Claimant to extend ihe course of treatment beyond the period of time or
number of treatments that relates to an Urgent Care Claim shall be decided as soon as
possible, taking into account the medical exigencies, and AvMed shall notify the Claimant of
the benefit determination, whether adverse or not, within 24 hours after AvMed receives the
Claim, provided that any such Claim is made to AvMed at least 24 hours before the
expiration of the prescribed period of time or number of treatments. Notification and appeal
of any Adverse Benefit Determination concerning a request to extend the course of
treatment, whether involving an Urgent Care Claim or not, shall be made in accordance with
the remainder of Part XV.
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) 15.06 l\lanner and content of initial claims determination notification. AvMed shall provide a Claimant
with written or electronic notification of any Adverse Benefit Determination. The notification shall set
forth, in a manner calculated to be understood by the Claimant, the following:
15.06.04
The specific reasons for the Adverse Benefit Determination.
Reference to the specific Plan provisions on which the determination is based.
A description of any additional material or information necessary for the Claimant to perfect
the Claim and an explanation of why such material or information is necessary.
A description of AvMed's review procedures and the time limits applicable to such
procedures, including, when applicable, a statement of the Claimant's right to bring a civil
action under Section 502(a) of the Employee Retirement Income Security Act of 1974, as
amended (ERISA), following an Adverse Benefit Determination on final review.
15.06.05 If an internal rule, guideline, protocol, or other similar criterion was relied upon in making
the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other
similar criterion or a statement that such rule, guideline, protocol or other similar criterion
was relied upon in making the Adverse Benefit Determination and that a copy shall be
provided free of charge to the Claimant upon request.
15.06.01
15.06.02
15.06.03
q
)
15.06.06 If the Adverse Benefit Determination is based on whether the treatment or service is
experimental and/or investigational or not Medically Necessary, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to the
Claimant's medical circumstances, or a statement that such explanation shall be provided
free of charge upon request.
15.06.07 In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a
description of the expedited review process applicable to such Claim.
15.07 Review procedure upon appeal. AvMed's appeal procedures shall include the following substantive
procedures and safeguards:
15.07.01 Claimant may submit written comments, documents, records, and other information relating
to the Claim.
15.07.02 Upon request and free of charge, the Claimant shall have reasonable access to and copies of
any Relevant Documents.
15.07.03 The appeal shall take into account all comments, documents, records, and other information
the Claimant submitted relating to the Claim, without regard to whether such information
was submitted or considered in the initial Adverse Benefit Determination.
)
15.07.04 The appeal shall be conducted by an appropriate named fiduciary of AvMed who is neither
the individual who made the initial Adverse Benefit Deterrnination nor the subordinate of
such individual. Snch person shall not defer to the initial Adverse Benefit Determination.
15.07.05 In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part
on a medical judgment, including determinations with regard to whether a particular
treatment, medication, or other item is experimental and/or investigational or not Medically
Necessary, the appropriate named fiduciary shall consult with a Health Professional who has
appropriate training and experience in the field of medicine involved in the medical
judgment.
15.07.06 The appeal shall provide for the identification of medical or vocational experts whose advice
was obtained on behalf of AvMed in connection with a Claimant's Adverse Benefit
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)
Determination, without regard to whether the advice was relied upon in making the Adverse
Benefit Determination.
)
15.07.07 The appeal shall provide that the Health Professional engaged for purposes of a consultation
in Subsection 15.07.05 shall be an individual who is neither an individual who was
consulted in connection with the initial Adverse Benefit Determination that is the subject of
the appeal, nor the subordinate of any such individual.
15.07.08 In the case of an Urgent Care Claim, there shall be an expedited review process pursuant to
which:
a) Request for an expedited appeal of an Adverse Benefit Determination may be snbmitted
orally or in writing by the Claimant; and
b) All necessary inforrnation, including AvMed's benefit determination on review, shall be
transmitted between Av Med and the Claimant by telephone, facsimile, or other
available similarly expeditious methods.
15.08 Manner and content of appeal notification. AvMed shall provide a Claimant with written or
electronic notification of AvMed's benefit determination upon review.
15.08.01 In the case of an Adverse Benefit Determination, the notification shall set forth, in a marmer
calculated to be understood by the Claimant, all of the following, as appropriate:
a) The specific reasons for the Adverse Benefit Determination.
b) Reference to the specific Plan provisions on which the Adverse Benefit Determination
is based.
c)
c) A statement that the Claimant is entitled to receive, upon request, and free of charge,
reasonable access to, and copies of any Relevant Documents.
d) A statement describing any voluntary appeal procedures offered by AvMed and the
Claimant's right to obtain the information about such procedures and a statement of the
Claimant's right to bring an action under ERISA Section 502(a) when applicable.
c) If an internal rule, guideline, protocol, or other similar criterion was relied upon in
making the Adverse Benefit Determination, either the specific rule, guideline, protocol,
or other similar criterion or a statement that such rule, guideline, protocol, or other
similar criterion was relied upon in making the Adverse Benefit Determination and that
a copy shall be provided free of charge to the Claimant upon request.
f) If the Adverse Benefit Determination is based on whether the treatment or service is
experimental and/or investigational or not Medically Necessary, either an explanation
of the scientific or clinical judgment for the determination, applying the terms of the
Plan to the Claimant's medical circumstances, or a statement that such explanation shall
be provided free of charge upon request.
XVI. MISCELLANEOUS
16.01 Applicability of law. The provisions of this Contract shall be deemed to have been modified by the
parties, and shall be interpreted, so as to comply with the laws and regulations of the State of Florida
and the United States.
16.02 Assigmnent. This Contract, and all rights and benefits related thereto, may not be assigned by the
Subscribing Group or the Mcmbcrs without written consent of AvMed.
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)
o
)
)
16.03 Certificate of Coverage. AvMed shall provide a copy of the Certificate of Coverage for each Subscriber.
No changes or amendments to this Contract shall be valid unless approved by an executive officer of
AvMed and endorsed herein or attached hereto. No agent has authority to change this Contract or to
waive any of its provisions.
16.04 Circnmstances not reasonably within the control of AvMed. In the event of circumstances not
reasonably within the control of AvMed, including major disasters and under such circumstances as
complete Of partial destruction of facilities, an act of God, war, riot, civil insurrection, disability of a
significant part of Hospital or participating medical personnel or similar causes, if the rendition of
Medical Services and Hospital Services provided under this Contract is delayed or rendered impractical,
neither AvMed, Participating Providers, nor any physician shall have any liability or obligation on
account of such delay or failure to provide services; however, AvMed shall make a good faith effort to
arrange for the timely provision of covered services during such event.
16.05 Clerical errors. Clerical errors shall neither deprive any individual Member of any benefits or coverage
provided under this Group Contract nor shall such errors act as authorization of benefits or coverage for
the Member that is not otherwise validly in force. Retroactive adjustments in coverage, for clerical
errors or otherwise will only be done for up to a 60 day period from the date of notification. Refunds of
premiums are done for up to a 60 day period from the date of notification. Refunds of premiums are
limited to a total of 60 days from the date of notification of the event, provided there are no Claims
incurred subsequent to the effective date of such event.
16.06 Contracting parties. By execnting this Contract, Subscribing Group and AvMed agree to make the
Medical Services and Hospital Services specified herein available to persons who are eligible under the
provisions of Part IV. However, the delivery of benefits and services covered in this Contract shall be
subject to the provisions, Limitations, and Exclusions set forth herein and any amendments,
modifications, and Contract termination provisions specified herein and by the mutual agreement
between Av Med and Subscribing Group, without the consent or concurrence of the Members. By
electing or accepting Medical Services and Hospital or other benefits hereunder, all Members legally
capable of contracting and the legal representatives of all Members incapable of contracting, agree to all
terms, conditions, and provisions hereof.
16.07 Contract review. Subscribing Group may, if this Contract is not satisfactory for any reason, return this
Contract within three days after receipt and receive a full refund of the deposit paid, if any, unless the
services of AvMed were utilized during the three days. If this Contract is not returned within three days
after receipt, then this Contract shall be deemed to have been accepted.
16.08 Entirety of Contract. This Agreement and all applicable schedul~s, exhibits, riders, amendments and
any other attachments and endorsements, constitute the entire Contract between the Subscribing Group
and AvMed. No modification (or oral representation) of this Group Contract shall be of any force or
effect unless it is in writing and signed by both parties.
16.09 ERISA. When this Contract is purchased by the Subscribing Group to provide benefits under a welfare
plan governed by ERISA, AvMed shall bc considered a fiduciary to the extent that it perfornls any
discretionary functions on behalfofthe Plan. lfa Member has questions about the group's welfare plan,
the Member should contact the Subscribing Group.
16.10 Gender. Whenever used, the singular shall include the plural and the plural the singular and the use of
any gender shall include all genders.
"16.11 Identification cards. Cards issued by AvMed to Members pursuant to this Contract are for purposes of
identification only. Possession of an AvMed identification card confers no right to health services or
other benefits under this Contract. To be entitled to such services or benefits the holder of the card
must, in fact, be a Member on whose behalf all applicable charges under this Contract have actually
been paid and accepted by AvMed.
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16.12 Membership Application. Members or applicants for membership shall complete and submit to AvMed
such applications or other forms or statements as AvMed may reasonably request. If Member or
applicant fails to provide accurate information which AvMed deems material then, upon ten days written
notice, AvMed may deny coverage and/or membership to such individual. Any person who knowingly
and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application
containing any false, incomplete, or misleading information is guilty of a felony, punishable as provided
by the Florida Statutes.
16.13 Non-waiver. The failure ofAvMed to enforce any of the provisions of this Contract or to exercise any
options herein provided or to require timely performance by any Member or Subscribing Group of any
of the provisions herein, shall not be construed to be a waiver of such provisions nor shall it affect the
validity of this Contract or any part thereof or the right of AvMed to thereafter enforce each and every
such provision.
16.14 Notice. Any notice intended for and directed to a party to this Contract, unless otherwise expressly
provided, should be sent by United States mail, postage prepaid, addressed as follows:
If to AvMed, to: AvMed
P. O. Box 749
Gainesville, Florida 32602-0749
(OR if from a Member to AvMed, see the Member's Service Area address listed on Page L)
If to a Member: To the last address provided by the Member and actually received by AvMed on the
enrollment application or change of address notification.
If to Subscribing Group: To the address provided in the Group Master Application.
16.15 Plan administration. AvMed may from time to time adopt reasonable policies, procedures, rules, and
interpretations to promote the orderly and efficient administration of this Contract.
16.16 Premium tax/surcharge. If any government entity shall impose a premium tax or surcharge, then the
sums due from the Subscribing Group under the terms of this Contract shall be increased by the amount
of such premium tax or surcharge.
16.17 Rate letter. The 'rate letter' is AvMed's formal notice to the Subscribing Group of the premiUln rates
applicable to the Subscribing Group, the conditions under which the rates are valid, the premium
payment terms and due dates, the additional charge which will apply to all late premium payments,
AvMed's reservation of the right to adjust (re-rate) the premium quote to account for changes in the
group size or in the data supplied by the Subscribing Group to AvMed, the applicable employer-
employee contribution to the premium payment and the charge for other optional, supplemental benefits
selected by the Subscribing Group, if any.
16.18 Third party beneficiary. This Contract is entered into exclusively between the Subscribing Group amd
AvMed. This Contract is intended only to benefit the Subscribing Group and the Members and does not
confer any rights on any other third parties.
16.19 Waiver. A Claim that has not been timely filed with AvMed within one year of date of service shall be
considered waived.
)
)
)
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AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application
AvMED
HEALTII PLANS
Contract Number(s):
Subscribing Group Name:
Effective Date:
108497
City of Sunny Isles Beach
03101/10
Group Contract
This Group Contract provides the benefits listed below:
o
Identifier
A V-CHOICE-3DD-09
A V-LG-RX-2x-1 0/20/30/75/50%-OC-B-09
AV-CHOICE-MHPH-09
RI-SA-CH-5299
AV-Choice-ETP-Co-insurance OOP-05
Descriotion
Summary of Benefits
Prescription Drug
IP Mental Health
Substance Abuse
ETOP
Eliaibilitv
Active Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this Contract.
Employees will become eligible for coverage on the first of the month following the first day of employment.
Management Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this
Contract. Employees will become eligible for coverage on the first of the month following the first day of employment.
Termination
For Active Employees (Class 1), termination of coverage under this Contract shall become effective End of Month.
For Management Employees (Class 1), termination of coverage under this Contract shall become effective End of Month.
I J Monthlv Membershio Charaes
Subscriber Only
$515.78
Subscriber plus Spouse ......................
$1,145.05
$964.36
$964.36
$1,459.36
Subscriber plus One Dependent (No Spouse) ..........
Subscriber plus Two or More Dependents ................
Subscriber plus Spouse and One or More Dependents .......
AV-Master Application-07
MP-2027 (1107)
')
AVMED, INC. d/b/a AVMED Health Plans
Group Medical and Hospital Service Contract
Group Master Application, continued
Aareement
This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital
services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED, Inc.
d/b/a AVMED Health Plans and the Subscribing Group. This Contract shall remain in effect for a period of twelve (12)
months from the effective date of March 1, 2010 and may be renewed annually, not later than the anniversary date, upon
mutual agreement of the parties. This Contract period begins at 12:01 a.m. 'Eastern Standard Time on the effective date or
on the anniversary date, if a renewal. The Contract shall be governed by Chapter 641, Florida Statutes, and other applicable
State and Federal laws.
10
The first monthly payment is due on March 1, 2010. Subsequent payments are due on the 1 st day of each month
thereafter.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
The provisions contained in the Schedule of Benefits applicable to this Contract and all Exhibits and Amendments executed
by the parties and attached hereto are, by reference, made a part of this Contract.
AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written.
2010.
::M:O;CVMA:~
I Signature
Patricia Nelson
Name
Director of Client Services
Date:
(p lo /;~
AV-Master Application-07
MP-2027 (1/07)
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY
4............. '4.....~
HANs OITINOT, CITY A RNE~
I')
Benefit Summary
CH.CH.5011
AvMED
H E ^ L t"H-PL^NS
COST TO MEMBER
AvMed PHCSloulsld. Out 01 Network
AvMedSmiceAleal
Unlimited $2,000,000
$500/$1,000 $500/$t,000 $1,000/$2,000
$2,500/$5,000 $2,500/$5,000 $5,000/$10,000
NETWORK
LIfE TIME MAXIMUM
CALENDAR YEAR DEDUCTIBLE (accumulales across all benollllovels)
tNDIVIDUAL / FAMtL Y
17/e Deductible does not apply IowaI'd the Olll-al-Pocket AfaTiwu//l
OUT.Of.POCKET MAXIMUM (accumulales across all benefit levels)
INDIVIDUAL (per calendar year) / FAMILY (per calendar year)
771i! Out-af-Pocket AlaTilllllf1l includes Co-payment and Co-insurance amounts
unless othelll'ise excluded
BENEfITS ARE NOT SUBJECT TO DEDUCTIBLE UNLESS OTHERWISE NOTED
PREVENTIVE CARE (nol subject 10 Deductible)
Preventive care services include but are not limited to:
Pediatric care and well.child care
. Well-woman examinations, including pap smears
Preventive care provided in a physician's oflice
Periodic health evaluations and immunizations
l)
$20 per Primary Care
office visit
OR
$40 per Specialist
office visit
$20 per Primary Care
office visit
OR
$40 per Specialist
office visit
40% oFthe Maximum
Allowable Payment
Calendar year
maximum benefit of
S300
PRIMARY CARE PHYSICIAN
$20 per visit
$20 per visit
40% of the Maximum
Allowable Payment,
after Deductible
MATERNITY CARE
. Initial visit
. Subsequent visits
$40 Co-payment
No Charge
Same as Choice
Network benefit
30% of the Maximum
Allowable Payment,
after Deductible
SPECIALITY HEALTH CARE PHYSICIAN SERVICES
Additional charges ,viII apply if Outpatient Diagnostic Tests arc performed
in the Specialist oflice.
$40 per visit
$40 per visit
40% of the Maximum
Allowable Payment,
after Deductible
HOSPITAL (Prior authorIzation required for Inpatlenl care)
Inpatient care at Participating Hospitals includes:
Room and board- unlimited days (semi~private)
. Physicians', specialists' and surgeons' services
Anesthesia, use of operating and recovery rooms, oxygen, drugs and
medication
. Intensive care units and other special units, general and special duty
nursing
Laboratory and diagnostic imaging
Required special diets
Radiation and inhalation therapies
OUTPATIENT SERVICES
Outpatient surgeries, including cardiac catheterizations and
angioplasty
Outpatient therapeutic services, including:
Drug infusion therapy
Injectable Drugs (Co.payment for Injectable Drug waived if
incidental to same-day drug infusion therapy)
Preventive and diagnostic colonoscopies (One preventive colonoscopy
per Ii fetime at no charge)
OUTPATIENT DIAGNOSTIC TESTS
CAT SClll1, PET Scan, MRt
Other diagnostic imaging tests
Outpatient laboratory tests
. Mammography (not subject to the Deductible)
Charges for office visits \vill also apply if services are performed in a
Specialist office.
EMERGENCY SERVICES
An emergency is the sudden and unexpected onset of a condition requiring
immediate medical or surgical care. (Co-payment ,vaived if admitted)
A\'Med must be notified within 24 hours ofinpalient admission
followin~ emergency sen'ices or as soon as reasonably possible
A V-CHOICE-3DD-09
MP-5011 (10/09)
$250 per day for the
first 5 days; 100%
coverage thereafter
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
No Charge
No Charge
$100 Co-payment
$250 per day for lhe
first 5 days; 100%
coverage thereafter
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
No Charge
Same as Choice
Net\vork benefit
40% of the Maximum
Allowable Payment,
after Deductible
40%ofthe Maximum
Allowable Payment,
after Deductible
40%ofthe Maximum
Allowable Payment,
after Deductible
Mammography
subject to Pre\'cnth:e
Care maximum
benefit of$300
Same as Choice
Nelwork benefit
I')
Benefit Summary, continued
URGENT/lMMEDlATE CARE
Medical Services at an Urgent/Immediate Care facility or services
rendered after hours in your Primary Care Physician's office
. Medical Services at a retail clinic
FAMILY PLANNING
. Voluntary family planning services
. Sterilization (In addition to any Outpatient facility Co-payment)
ALLERGY TREATMENTS
. Injections
. Skin testing
AMBULANCE
. Ambulance transport for emergency services
10
. Non-emergent ambulance services are covered when the skill of
medically trained personnel is required and the Member cannot be
safely transported by other means
PHYSICAL, SPEECH AND OCCUPATIONAL THERAPIES
ShorHenn physical or occupational therapy for acute conditions.
Coverage is limited to 30 visits per calendar year for all services
combined
Speech benefit is limited to 24 visits per calendar year
DIAGNOSIS and TREATMENT OF AUTISM SPECTRUM DISORDER
. Applied Behavior Analysis services
. Physical, speech or occupational therapy for the treatment of Autism
Spectrum Disorder
Coverage for all services related to Autism Spectrum Disorder is limited to
$36,000 annually and may not exceed $200,000 in total benefits.
SKILLED NURSING FACILITIES and REHABILITATION CENTERS (Prior
authorization requIred)
Up to 20 days post-hospitalization care per calendar year when prescribed
by physician and authorized by AvMed
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions: acute
myocardial infarction, percutaneous trans luminal coronary angioplasty
(PTCA), repair or replacement of heart valves, coronary artery bypass graft
(CABG) or heart transplant.
Coverage is limited to a maximum of 18 \'isits per calendar }'ear or
$1,500, whichenr is exhausted first
HOME HEALTH CARE
Limited to 60 skilled visits per calendar year
$40 Co-payment $40 Co-payment $60 Co-payment
$20 Co-payment $20 Co-payment $60 Co-payment
20% of the contracted 20% of the contracted 40% of the Maximum
rate, after Deductible rate, after Dcductible Allowablc Payment,
after Deductible
20% of the contractcd 20% of the contractcd 40% of the Maximum
rate, after Deductible rate, after Deductiblc Allowable Payment,
after Deductible
20% of the contracted Same as Choice 20% ofthc Maximum
rate, after Deductible Network benefit Allowable Payment,
after Deductible
20% of the contracted 20% of the contracted 40% of the Maximum
rate, after Deductible rate, after Deductible Allowable Payment,
after Deductible
20% of the contracted 20% of the contracted 40% of the Maximum
rate, after Deductible rate, after Deductible Allowable Payment,
after Deductible
$40 per visit $40 per visit 40% of the Maximum
20% of the contracted 20% of the contracted Allowable Payment,
rate, after Deductible rate, after Deductible after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
ratc, after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
40% of the Maximum
Allowable Payment,
after Deductible
40%ofthe Maximum
Allowable Payment,
after Deductible
40%ofthe Maximum
Allowable Payment,
after Deductible
DURABLE MEDICAL EQUIPMENT AND ORTHOTIC AND ORTHOPEDIC
APPLIANCES
Equipment includes:
. Hospital beds, walkers, crutches and \vhee1chairs
Orthotic appliances are limited to:
. Custom-made leg, arm, back and neck braces
Benefits limited 10 combined $3,000 per calendar year
PROSTHETIC DEVICES
Prosthetic devices are limited to:
. Artificial limbs, artificial joints and ocular prostheses
ALL OTHER COVERED SERVICES
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
40% of the Maximum
Allowable Payment,
after Deductible
40%ofthe Maximum
Allowable Payment,
after Deductible
40% of the Maximum
Allowable Payment,
after Deductible
PRIOR AUTHORIZATION IS REQUIRED FOR SPECIFIC COVERED SERVICES, THE PENALTY FOR NON-NOTIFICATION IS $500,
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1.800-88-AVMED (1-800-882-8633)
This Schedule of Benefits is not a Contract. For specific infonnation on benefits, Exclusions and Limitations, please see your AvMed Choice Group
Medical and Hospital Service Contract with Point of Service Rider.
A Y-CHOICE-3DD-09
MP-5011 (10/09)
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
20% of the contracted
rate, after Deductible
f)
Prescription Medication Benefits
AvMED.
HEALTH PLANS
o
$1 O/20130nS/50% CO.PAYMENT with Contraceptives
DEFINITIONS
llnmd medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a phannaceutical manufacturer or a
medication that is identified as a Brand medication by AvMed. AvMed delegates determination of GcnericIBmnd status to our Ph,mllilcy Benefils Manager.
Hrand Additional Char~c me;ms the additional charge that must be paid if you choose a Bmnd medication when a Generic equivalent is available. The
charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to the applicable Non.
Preferred Brand Co-pa)1ncnt. However, if the prescribing physician or other Participating Provider authorized to prescribe medications within the scope of his
or her license indicates on the prescription Bnmd medically necessary or dispense as written for a medication for which there is a generic equivalent, the Brand
medication shall be dispensed for the applicable Non-Preferred Brdfld Co-payment only.
Cost-sharing Medications are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively minor
non-life threatening conditions. Such medications are subject to Co-insurnnce and covemge is limited as outlined below.
Dental.specUic I\.'lcdication is medication used for dental-specific purposes, including but not limited to fluoride medications and medications packaged and
labeled for dental-specific purposes.
Formulary List means the listing of preferred and non-preferred medications as detemlincd by AvMed's Phannacy and Therapeutics Committee based on
clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi-tiered list establishes different levels of
Co-payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been
reviewed by AvMed's Pharmacy and Therapeutics Committee.
Generic medication me,ms a medication that ha<; the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's
Pharmacy Benefits Manager.
Injectable Medication is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the
following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection,
intracavemous injection or intraocular injection. Prior authorization is required for all Injectable Medications.
Maintenance Medication is a medication that has been approved by the FDA, for which the duration of therapy can reasonubly be expected to exceed one
year.
Pm1icipating Phanuacy means a pharmacy (retail, mail order or specialty ph;:mnacy) that has entered into an agreement with AvMed to provide Prescription
Drugs to AvMed Members and has been designated by AvMed as a Participating Phannacy.
Prescription nrug means a medication that has been approved by the IDA and that can only be dispensed pursuant to a prescription according to state and
federal law.
Prior Authorization means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed's guidelines. The
prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Prior Authorization is subject to periodic review llild
modification by AvMed. A copy of the list of medications requiring Prior Authorization and the applicable criteria are available from Member Services or from
the AvMed website.
HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK?
To obtain your Prescription Drug, take your prescription to, or have your physician call, llil AvMed Participating Pharmacy. Your physician should submit
prescriptions for Injectable Medications to AvMed's specialty pharmacy. Present your prescription along with your AvMed identification card. Pay the
following Co-payment (as well a<; the Brand Additional Charge if you choose a Brand product when a Generic equivalent is available).
TIer 1 Preferred Generic Medications:
TIer 2 Preferred Brand Medications:
TIer 3 Non-Preferred Brand or Generic Medications:
Tier 4 Injectable Medications:
Tier 5 Cost~sharing Medications:
ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL
Mail service is a benefit option for maintenance medications needed for chronic or long-tenn health conditions. It is best to get an initial prescription filled at
your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Up to
3 refills are allowed per prescription. Pay the following Co-payment (as well as the Brnnd Additional Charge if you choose a Brand product when a Generic
equivalent is available).
$ to.oo
$ 20.00
$ 30.00
$ 75.00
50%
Co-payment
Co-payment
Co-payment
Co-payment
Co-Insurance
Tier 1
TIer 2
TIer 3
Tier 4
TierS
Preferred Generic Medications:
Preferred Brnnd Medications:
20.00
40.00
60.00
Co-payment
Co-payment
Co-payment
$
$
Non-Preferred Bnmd or Generic Medications: $
Injectable Medications are not available through mail service
Cost-sharing Medications arc not available through mail service
A V -LG-RX.2x-1 0I20/30nS/50%-B-09
MP-4000 (10109)
f')
Prescription Medication Benefits, continued
WHAT IS COVERED?
. Your Prescription Drug coverage includes outpatient medications (including contrJ.ceptives) that require a prescription and are prescribed by your AvMed
physician in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for covered pnx:lucts and services.
Coverage criteria arc medical and pharmaceutical protocols used to dctcnnine payment of producto; and services and are based on independent clinical
practice guidelines and standards of care established by government agencies and medicallphmmaceutical societies.
. Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Program, for certain covered medications. The
Progressive Medication Progr.un encourages the use of theiJpcutically-equivalent lower-cost medications by requiring certain medications to be utilized to
treat a medical condition prior to approving another medication for that condition. This includes the first-line use of preferred medications that are proven to
be safe and effective for a given condition and can provide the same health benefit as more expensive non-preferred medications at a lower cost.
Your retail Prescription Drug coverage includes up to a 3D-day supply of a medication for the listed Co-payment. Your prescription may be refilled via
re~'lil or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have the opportunity to obtain a
90-day supply of medications used for chronic conditions including, but not limited to asthma, cardiovascular disease, and diabetes from the retail
pharmacy for the applicable Co-payment per 3D-day supply. However, Prior Authorization may be required for covered medications.
. Your mail-order Prescription Drug coveiJge includes up to a 90-day supply of a routine maintenance medication for the listed Co-payment. [f the amount
o of medication is less than a 90-day supply, you will still be charged the listed mail order Co-payment.
. Your Injectable Medication coveiJge extends to many injectable medications approved by the FDA. These medications must be prescribed by a physici;:m
and dispensed by a retail or specialty phannacy. The Co-payment levels for Injectable Medications apply regardless of provider. This means that you arc
responsible for the appropriate Co-payment whether you receive your Injectable Medication from the phannacy, at the physician's office or during home
health visits. Injectable Medications are limited to a 3D-day supply.
. Your Prescription Drug coveiJge includes coverage for injectable contraceptives. There is a Co-payment of $30 for each injection. If there is an office visit
associated with the injection, there will be an additional Co-payment required for the office visit.
. Quantity limits are set in accordilllce with FDA approved prescribing limitations, general practice guidelines supported by medical s~cialty organizations,
and/or evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific qmmtity limit may apply
for medications that have an increased potential for over-utilization or an increased potential for a Member to experience an adverse effect at higher doses.
QUESTIONS? Call your AvMed Member Services Department at: t -800-88-AvMed (1-800-882-8633)
EXCLUSIONS AND LIMITATIONS
. Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative is available, unless otherwise
indicated on AvMed's Fonnulary List.
. Medications not included on AvMed's Fonnulary List.
. Medical supplies, including therapeutic devices, dressings, appliances and support garments
. Replacement Prescription Drug products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill
. Diaphragms and other contraceptive devices
. Fertility drugs
. Medications or devices for the diagnosis or treatment of sexual dysfunction
. Dental-specific Medications for dental purposes, including fluoride medications
. Prescription and non-prescription vitamins and minerals except prenatal vitamins
. Nutritional supplements
. Immunizations
. Allergy serums, medications administered by the Attending Physician to treat the acute pha<;e of illl illness and chemotherapy for cancer patient" are covered
in accordance with the Group Medical and Hospital Service Contract and may be subject to Co-payments or Co-insurance as outlined on the Schedule of
Benefits
. Investigational and experimental drugs (except as required by Ronda statute)
. Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun dmnage and anti-wrinkle medications
. Nicotine suppressants ;:md smoking cessation products and services
. Prescription and non-prescription appetite suppressants and products for the purpose of weight loss
. Compounded prescriptions, except pediatric preparations
. Medications and immunizations for non-business related travel, including Transdennal Scopolamine
Filling a prescription at a phannacy is flot a cfaimfor benefits and is 1Iot subject to the Claims and Appeals procedures Willer ERISA. Howel'er, WI)' medicines thaf
require Prior {/uthon.wtioll will be treated as a claim for benefits subject to the Claims and Appeals Pmcedllres, as outlined in the Gmup Medical and Hospital Se/vice
Contract.
A V -LG-RX-2x:-1 O/20/30n5/50%-09
MP-4000 (10/09)
')
AvMED
HEALTII PLANS
Amendment
ELECTIVE TERMINATION OF PREGNANCY
I f selected, the following optional coverage is hereby added:
The Group Medical and Hospital Service Contract with Point-of-Service Rider is amended to state:
.
Elective termination of pregnancy will be a covered benefit subject to the applicable facility
deductible and co-insurance as outlined on the Benefit Summary,
Charges incurred by you for these services will apply toward the annual out-of-pocket maximum.
.
o
A V-Choice-ETP-Co-insurance OOP-OS
MP-3635 (12/04)
I')
Amendment
AvMED
HEALTH PLANS
Mental Health Services
As of the effective date, outpatient and inpatient mental health services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
I
10
. Outpatient mental health services are covered subject to the Member's cost sharing responsibility
for specialist services,
. Inpatient or partial hospitalization for mental health services is covered when a Member is
admitted to a Hospital or Health Care Facility, Coverage is subject to the Member's cost sharing
responsibility for inpatient Hospital Services.
Prior authorization is required for mental health services. Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact A vMed at 1-800-882-8633,
A V-CHOtCE-MHPH-09
MP-5297 (10/09)
f)
Amendment
AvMED
HEALTH PLANS
Substance Abuse Services
As of the effective date, outpatient and inpatient substance abuse services are covered, when Medically
Necessary, subject to the following Member cost sharing responsibility:
. Outpatient substance abuse services are covered subject to the Member's cost sharing
responsibility for specialist services.
. Inpatient or partial hospitalization for substance abuse services is covered when a Member is
admitted to a Hospital or Health Care Facility. Coverage is subject to the Member's cost sharing
responsibility for inpatient Hospital Services.
o
Prior authorization is required for substance abuse services, Please consult the Schedule of Benefits for
Member cost sharing responsibility and Deductible information, if applicable. For further information,
contact AvMed at 1-800-882-8633,
A V-CHOICE-SAPH-09
MP-5299 (10/09)
I,
To:
Via:
FROM:
DATE:
RE:
City of Sunny Isles Beach
18070 Collins Avenue
Sunny Isles Beach, Florida 33160
CifY Commission
Norman S, EdeIcup, MtfYor
Lewis J. Thaler, Vice MtfYor
Roslyn Brezin, Commiuioner
Gerry Goodman, Commiuioner
George "Bud" Scholl, Commiuioner
(305) 947-0606 City Hall
(305) 949-3113 Pax
(305) 947.2150 Building Department
(305) 947-5107 Fax
Rick Conner, City Manager
Hans Ottinot, City Aflomry
Jane A. Hines, Ci!Y Clerk
MEMORANDUM
The Honorable City Commission
Rick Conner, City Manager
Doug Haag, Asst. City Manager-Finance
February 18,2010
HEAL TH, DENTAL, LIFE, DISABILITY AND VISION INSURANCE
RENEWAL - EFFECTIVE MARCH 1,2010
RECOMMENDATION:
It is recommended that the City Commission adopt the attached resolution renewing the City's
existing employee insurance benefit providers as follows:
Coverage Type Pr vider Effective Date
Health Insurance AvMed March 1,2010
Dental Insurance Lincoln Financial Group March 1, 2010
Vision Insurance Eye Med March 1, 2010
Life Insurance Lincoln Financial Group March 1,2010
Accidental Death and Lincoln Financial Group March 1,2010
Dismemberment (AD & D )
Long Term Disability Lincoln Financial Group March 1,2010
BACKGROUND:
Last year at this time the City faced a challenging situation when our previous health insurance
provider (United Health Care) proposed an overall 39% increase in our premiums. As a result
of the efforts of our insurance agent - Brown & Brown - we were able to realize a significant
savings by placing our coverages with A vMed in March, 2009.
This year, AvMed's proposal includes a 12% increase. This represents an additional annualized
cost to the City of approximately $130,000 (this does not include the employee's share of
Funding available:
Approval:
\Dt>
~-~D
Agenda Item No,:
Finance Department
City Manager
MEMO 1O-02-18JIEALTJ-I INSURANCE RENEWAL (2)
Commission Meeting Date:
premiums). Our claims experience with AvMed is approximately 84%. As per the City's
insurance representative - Brown & Brown - this increase is less than most of their other
renewals which are averaging 15 - 20%. I've also spoken to Al Waters of Siver Consulting and
he felt this is "very reasonable" based on what he is seeing in the market today. That is, his
experience this past year has been that 12 - 13% increases are the minimum that most providers
are seeking due to rising medical costs. And, that's with a loss ratio of 85% or less.
As part of the renewal process this year, Brown & Brown again met with City staff representing
all departments to determine the overall level of satisfaction with the current providers. After an
in-depth discussion regarding providers, coverages, premiums and customer service the
consensus was to remain with AvMed.
Health Insurance - As in previous years the city's Brown & Brown issued proposals to
prospective firms on behalf of the City. Their mission was to provide for the same level of
benefits as employees currently have. Proposals were submitted to the following firms with their
response indicated:
1. Aetna- Declined based on claims history
2. Cigna- Declined based on claims history
3. AvMed -Quoted 12% increase
4. UnitedlNHP- Have not provided a quote
5. Humana- Have not provided a quote
6. Vista - Provided a proposal with comparable rates but coverages were much less
7. BCBS- Have not provided a quote
Based on the above, the City's review team concurs with the Brown & Brown recommendations:
. Continuation of AvMed as the healthcare provider with an average of 12% in annualized
premiums. The plans selected are the HMO-OA 5228, POS-OA 5011 and HMO-OA
5076. The third plan is the lower cost option that we started making available two years
ago.
. Continuation of Lincoln Financial Group as the provider for dental, life, disability and
accidental death & dismemberment (ADD). The dental insurance renewal premium has
increased by 27% based on a loss experience of 137%. Other premiums have increased
nominally, i.e. less than 5%. Approximate annualized cost of the increases is $30,000.
. Continuation of Eye Med as the provider for the vision insurance.
The estimated cost of these insurances for the balance of this fiscal year is $80,000. Funds are
currently budgeted in the line item account 5230 within each department and no transfers are
needed at this time.
Weare also going to meet with Brown & Brown to discuss a possible reduction in their
commission fee.