HomeMy WebLinkAboutResolution_30-98/99_04/08/1999 RESOLUTION NO. 30 -98/99
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF
TEQUESTA, PALM BEACH COUNTY, FLORIDA, AWARDING BID TO
FLORIDA MUNICIPAL INSURANCE TRUST FOR VILLAGE OF TEQUESTA
EMPLOYEES' GROUP HEALTH INSURANCE, AND AUTHORIZING THE
VILLAGE MANAGER TO EXECUTE DOCUMENTS NECESSARY TO
EFFECTUATE THE SAME ON BEHALF OF THE VILLAGE.
OW, THEREFORE BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE VILLAGE
OF TEQUESTA, PALM BEACH COUNTY, FLORIDA AS FOLLOWS:
Section 1. The Bid with Florida Municipal Insurance Trust for
Village of Tequesta Employees' Group Health
Insurance, Attached Hereto as Exhibit "A" and
Incorporated by Reference as Part of this Resolution
is Hereby Approved and the Village Manager of the
Village of Tequesta is Authorized to Execute
Documents Necessary to Effectuate the Same on Behalf
of the Village, Unless a Majority of the Employees
Disapprove of Same.
THE FOREGOING RESOLUTION WAS OFFERED by Councilmember Basil E. Dalack
who moved its adoption. The motion was seconded
by Councilmember Carl C. Hansen and upon being put to
a vote, the vote was as follows:
FOR ADOPTION AGAINST ADOPTION
Joseph N. Capretta Ron T. Macka.il
Basil E. Dalack Elizabeth A. Schauer
Carl C. Hansen
The Mayor thereupon declared the Resolution duly passed and adopted
this 8 day of April, A.D. , 1999.
MAYOR OF TEQUESTA
40 ATTEST:
Joann Manganie to
Village Clerk
Exhibit "A"
Health Rate Options
POS Gold
Employee Medical $175.36
Spouse Medical $199.92
Child(ren) Medical $149.06
MEDICARE SUPPLEMENT $161.00
•
Florida Municipal Insurance Trust
Major Plan Benefit In Network Out of Network
Calendar Year Deductible:
Individual 0 $300
Family 0 $900
Maximum Out of Pocket:
Individual $1,000 $2,000
Family $2,000 $4,000
Lifetime Maximum $1,000,000 $1,000,000
Hospital Services
♦ Inpatient $100-00 Co-Pay, then 100% $500.00 Deductible,
Services of covered expenses then 80% of covered
expenses
♦ Outpatient 100% of covered expenses 80% of covered expenses
Services after deductible
♦ Emergency Room $50.00 Co-Pay, then 100% $50.00 Co-Pay, then 100%
Services of covered expenses of covered expenses
Physician Services
• Preventative Care $10.00 Co-Pay Not Covered
• Routine Services $10.00 Co-Pay 80% of reasonable charges
• Well Child Care $10.00 Co-Pay 80% of reasonable charges
• Specialty Care $10.00 Co-Pay 80% of reasonable charges
• OB/GYN Care $10.00 Co-Pay 80% of reasonable charges
• Allergy Injections $10.00 Co-Pay 80% of reasonable charges
• Surgical Expense 100% 80% of reasonable charges
• Maternity Care $10.00 Co-Pay, 80% of reasonable charges
1St Visit, then 100%
•
Florida Municipal Insurance Trust
Other Health Care Services In Network Out of Network
♦ Prescription Drugs $5.00 Generic Wholesale Price, less 10 %,
(RX Net) $10.00 Brand less In Network Co -Pay
♦ Mental & Nervous Disorder
• Inpatient Services $100.00 Co -Pay, $500.00 Deductible, then
(30 days per calendar year maximum) then 100% 80% of covered charges
• Outpatient Services $10.00 Co -Pay, 80% of covered charges
(20 visits per year limit) then 100% $50.00 per visit maximum
$10,000 calendar year maximum
$25,000 lifetime maximum
♦ Alcohol and Drug Dependency
• Individual Visit $10.00 Co -Pay 80% of covered charges
♦ Hospice Care 100% 80% of covered charges
(6 month maximum care)
• $6,000 lifetime maximum
♦ Home Health Care 100% 80% of covered charges
(60 visits per year maximum)
♦ Physical Therapy 100% 80% of covered charges
(40 visits per year maximum)
$2,000 calendar year maximum
♦ Skilled Nursing Facility 100% 80% of covered charges
(75 days per year maximum)
$10,000 lifetime maximum
♦ Chiropractic Services $10.00 per visit 80% of covered charges
(26 visits per calendar year) $40.00 per visit maximum
♦ Routine X -Rays, Lab Tests, 100% 80% of covered charges
Diagnostic Services
All surgical procedures must be pre - certified.
All non - emergency hospital stays must be pre- certified.
• All Out of Network Benefits are covered at 80% of reasonable and customary charges, after the calendar year deductible has been met.
All deductibles do not apply toward the annual maximum out of pocket expenses.
AII In Network Co -Pays apply toward the annual maximum out of pocket expenses.
The hospital deductible for Out of Network confinement due to an emergency does not apply.
(This is intended as a Summary of Benefits and does not include all of the benefits, limitations,
and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefits.)
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• Florida Municipal Insurance Trust
Certificate of Coverage
This Certificate of Coverage and Medical Master Plan of Benefits
("Certificate") sets forth your rights and obligations as a participant. It is
important that you READ YOUR CERTIFICATE CAREFULLY and familiarize
yourself with its terms and conditions.
The Plan may require that the participant contribute to the required
premiums. Information regarding the premium and any portion of the
premium cost a participant must pay can be obtained from your employer.
Florida Municipal Insurance Trust ( "Trust") agrees with your employer to
provide coverage for medical services, subject to the terms, conditions,
exclusions and limitations of the plan. The plan is issued on the basis of
the Participation Agreement of the employer and payment of the required
plan charges. The employer's application is made a part of the contract.
The Trust shall not be deemed or construed as an employer for any purpose
with respect to the administration or provision of benefits under the
• employer's benefit plan. The Trust shall not be responsible for fulfilling
any duties or obligations of an employer with respect to the employer's
benefit plan.
The Trust has sole and exclusive discretion in interpreting the benefits
covered under the plan and the other terms, conditions, limitations and
exclusions set out in the plan and in making factual determinations related
to the plan and its benefits. The Trust may, from time to time, delegate
discretionary authority to other persons or entities providing services in
regard to the plan.
The Trust reserves the right to change, interpret, modify, withdraw or add
benefits or terminate the policy, in its sole discretion, without prior notice
to or approval by participants. No person or entity has any authority to
make any oral changes or amendments to the policy.
Please show your plan identification card each time you request health care
services. This is to ensure that the providers know that you are part of the
plan; otherwise you may receive a bill for health care services.
This plan shall take effect on the date specified and will be continued in
force by the timely payment of the required plan charges when due, subject
• to termination of the plan as provided. All coverage under the plan shall
begin at 12:01 a.m. and end at 12:00 midnight Eastern time.
Florida Municipal Insurance Trust
Medical Master Plan of Benefits_
TABLE OF CONTENTS
a
Section Heading Page
I. DEFINITIONS ----------------------------------- j----------------------- ------ 1
II. DEDUCTIBLES --------------------------------------------------------- - - - - -- 6
III. LIFETIME MAXIMUM AND RESTORATION OF BENEFITS--- - - - - -- 6
IV. MAXIMUM EXPENSE TO PARTICIPANTS ------------------------ - - - - -- 7
V. ELIGIBILITY AND ENROLLMENT.---------------------------------- - - - - -- 7
VI. COVERED EXPENSES ------------------------------------------------- - - - -
VII. HOSPITAL BILL SELF -AUDIT ---------------------------------------- - - - -19
VIII. EXCLUSIONS AND LIMITATIONS----------------------------------- - - - -20
IX. COORDINATION OF BENEFITS ------------------------------------- - - - -23
X. PRE - EXISTING CONDITIONS LIMITATIONS -------------------- - - - - -24
XI. TIME OF PAYMENT, GRACE PERIOD------------------------------ - - - -25
XII. CONDITIONS FOR RENDERING SERVICE ---------------------- - - - - -- 25
XIII. EMPLOYER'S TERMINATION AND RENEWAL ------------------- - - - -26
XIV. PARTICIPANT'S TERMINATION OF COVERAGE -------------- - - - - -- 26
XV. CONTINUATION OF COVERAGE - COBRA ------------------------ - - - -2S
XVI. PRESCRIPTION DRUGS --------------------------------------------- - - - - -- 30
XVII. GENERAL PROVISIONS --------------------------------------------- - - - - -- 31
XVIII. PAYMENT OF BENEFITS, ASSIGNMENT ------------------------ - - - - -- 33
XIX. GRIEVANCE PROCEDURES __________________ ________________________ _ _ _ _33
XX. SUBROGATION---------------------------------------------------------- - - - -
XXI NOTICE ----------------------------------------------------------------- - - - - -- 34
•
Florida Municipal Insurance Trust Medical Master Plan of Benefits
SECTION I — DEFINITIONS
• Accident means a non - occupational, unforeseeable, unintentional and unplanned
event resulting in a traumatic injury to a participant occurring while this Plan is
in force and resulting directly and independently of all other causes in loss
covered by this Plan. The acts of bending, stooping, lifting, stretching or standing
are covered as a sickness as defined herein.
Active Employee means an eligible employee who is performing all of his or her
regular duties on a full-time basis for the Employer on a regularly scheduled work
day. _.
Benefits or Coverages means those hospital, medical, surgical and authorized
related expenses as hereinafter provided, for which °payment shall be made to, or
on behalf of, a participant.
Birthing Center means a state - licensed facility or institution equipped to provide and
provides prenatal care, delivery, immediate postpartum care of a child at the
facility, has a physician or Certified Nurse Midwife present at all births and
immediate postpartum period, provides full-time nursing services directed by a
Registered Nurse or Certified Nurse Midwife, and keeps medical records on each
patient and child. A birthing center is not an ambulatory surgical facility or a
hospital.
Calendar Year means a period of twelve (12) consecutive months commencing on
January 1 and ending on December 31 in any given year. For participants
enrolling during a calendar year, the Calendar Year begins on the effective date of
their enrollment and ends on December 31 of that same year.
Certified Nurse Midwife means a person who is licensed by the state as an advanced
Registered Nurse Practitioner under Ch. 464, F.S., and who is certified to practice
midwifery by the American College of Nurse Midwives.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985 (H.R.
3128) signed into law on April 17, 1986 as Public Law 99 -272, as amended.
Co —Pay means the charge that the participant is required to pay for certain covered
expenses provided under the Plan. This may be defined as either a dollar amount
or a percentage of covered expenses. The participant is responsible for the
payment of any Co -Pay directly to the Service Provider at the time of service.
Contract means this agreement between the Trust and the employer by virtue of
which the employer and its eligible employees and their dependents become
participants; the Participation Agreement of the employer; The Agreement and
Declaration of Trust creating the Health Benefit Trust; the rules, regulations and
resolutions adopted by the Board of Trustees; the attached endorsements and
riders, if any; the individual applications of the employees; and the identification
cards issued to employees indicating their participation in the coverage provided
hereunder.
Covered Expenses means those eligible services as outlined in Section VI of this
Plan.
Dependent means the legal, married spouse of an employee and /or eligible legal,
unmarried (never married) dependent children as hereinafter described, residing
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Florida MUnV surance Trust • Florida Municipal Insurance Trust Medical P_Plan of Benefits
1� Medical Master Plan of Benefits
in the United States and its territories. Participation Agreement, and who has agreed to be bound by all the terms and
• child is a dependent if the child meets the following conditions: provisions of the Trust Agreement, the Participation Agreement and the rules and
(1) the child is a natural child, stepchild, legally adopted child, or a child regulations adopted by the Trustees in the administration of the Trust.
who has been placed under the legal court - ordered guardianship of the HIV infection or a specific sickness or medical condition derived from such
! participant, and
infectioa means the human immunodeficiency virus identified as the causative
(2) the child is in the custody of and financially dependent upon the agent of acquired immune deficiency syndrome, Acquired Immune Deficiency
participant. (This is waived if the participant is required to provide Syndrome, an acquired immune deficiency syndrome- related complex, or a
coverage to the child due to court order or divorce decree.) j specific sickness or medical condition derived from such infection.
Home Health Azen means any state licensed public agency or private organization
• newborn child of a participant having dependent coverage is entitled to the that is equipped to provide and provides home health services.
same benefits as the participant; provided, however, a dependent child shall not Home Health Services means any or all of the following health and medical services
be entitled to maternity benefits under this Plan. A newborn child of a dependent
and medical supplies when furnished to an individual by a home health agency in
child covered under the Plan shall terminate 18 months after the birth of the a place of residence used as a participant's home:
newborn child.
(1) part-time or intermittent nursing care provided by a Registered Graduate
A dependent child shall cease to be a participant at the end of the calendar year Nurse or a Licensed Practical Nurse;
in which such child reaches age 19. However, if such child is in full-time (2) physical, occupational, or speech therapy;
attendance at an accredited school, college, or university and is dependent upon (3) medical social services, home health aid services, and nutritional
the participant for support, coverage will continue until the end of the calendar guidance;
' year in which the child reaches age 25; or upon the marriage of such child,
whichever event shall first occur. Full-time attendance means that the student is (4) medical supplies, other than drugs or biologicals prescribed by a
enrolled.for -,the number of hours which is considered to be a full -time attend ce physician, and the use of medical appliances.
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by the institution the student is attending. Satisfactory roof of such attendance
g ry P e Hospice Care means care given to a terminally ill participant by or under
shall be furnished to the Trust upon request.
arrangements with a hospice care agency, and must meet the standards outlined
A dependent child, regardless of age, shall continue to be covered under this Plan by the National Hospice Association.
while the child is and continues to be:
(1) incapable of self - sustaining employment by reason of mental retardation Hospice Care Agency means a state licensed organization and which:
or physical handicap; and (1) has twenty-four (24) hour hospice care available; and
(2) chiefly dependent upon the employee for support and maintenance; (2) provides skilled nursing services, medical social services, psychological
provided such condition occurred while such dependent was covered and dietary counseling; and
under this Plan. Satisfactory proof of such continuing incapacity and (3) provides physician services, physical therapy, part-time home health aide
dependency must be furnished to the Trust. services and inpatient care; and
(3) The burden is on the participant to establish such dependent meets or (4) keeps medical records; and
continues to meet the criteria specified in (1) and (2). (5) has afull-time administrator.
Durable Medical Equipment means medical equipment designated for repeated use Hospital means an institution which is licensed and operated in accordance with the
and which is medically necessary to improve the functioning of a malformed body laws of the jurisdiction in which it is located pertaining to institutions identified
member, or to prevent further deterioration of the patient's medical condition. as hospitals, and which is primarily engaged in furnishing for compensation,
Employee means an officer or employee of the employer or any class or classes of diagnostic and therapeutic facilities for surgical and medical diagnosis, which
such employees, regularly working thirty (30) ** or more hours a week, who is provides treatment and care of injured and sick persons by or under the
eligible for coverage hereunder, who has been so designated by the employer and supervision of a staff of physicians who are duly licensed to practice medicine,
who holds a valid Social.Security Number. This definition shall include elected and which continuously provides twenty-four (24) hour a day nursing service by
officials of the employer and employees who have retired and are receiving Registered Graduate Nurses, and which is not, other than incidentally, a
retirement benefits pursuant to a retirement plan lawfully established and sanitarium, nursing home, place for rest, place for the aged, place for drug addicts
maintained by the employer. or place for alcoholics. "Hospital" also means:
(1) an institution which is an "ambulatory surgical center", as defined and
Emplover means each and every county, municipality, school board, special taxing licensed under Florida Statutes, or
district or local governmental unit established within, and pursuant to the laws (2) a "Psychiatric Hospital" which is an institution legally constituted and
' of, the State of Florida and which becomes a party to this Trust by executing a i
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Florida Mu n° Insurance Trust Medical Master Plan of Benefits Florida Municipal Insurance Trust Medicaildhilar Plan of Benefits
censed as a psychiatric hospital and properly accredited to rovide Physical Therapist means a person who is dui P Y u P y registered or licensed by the state in
psychiatric, diagnostic and therapeutic services for the treatment of which such person is engaged in the practice of physical therapy and who is a
patients who have mental illnesses. member of the American Physical Therapist's Association.
Hosvital Service means and includes receiving a participant into a hospital for Physical Therapy means the diagnosis, treatment, prevention, or rehabilitation of
services set forth in this Plan and outlined on the hospital bill and subject to the any injury, disease, or other health condition, including the use of apparatus and
rules and regulations of the hospital, for and during such time only s the equipment directly related thereto, by the use of physical, chemical and other
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participant is necessarily treated on an inpatient or outpatient basis in the properties of air; electricity; exercise; massage; radiant energy, including
hospital, under the treatment and care of a physician for any conditions covered ultraviolet, visible or infrared rays; ultrasound; or water; or by the use of
hereunder. acupuncture or tests of neuromuscular functions; provided such diagnosis,
treatment, prevention, or rehabilitation is performed pursuant to minimum
Inpatient means a patient who has been admitted upon order of a physician as a bed criteria and standards of practice established by a statutorily created board that
patient for treatment in a hospital for at least six (6) continuous hours. primarily consists of physical therapists and /or physicians and pursuant to a
Lifetime Maximum means the maximum liability of the Trust subject to the benefits written plan of treatment prescribed and approved by a physician.
provided in this Plan, with respect to each participant covered under this Plan, Phygician means a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) legally
during the entire period such participant is covered hereunder. qualified to practice medicine and perform surgery at the time and place the
service is rendered. For services covered under this Plan, doctors of dental
surgery (D.D.S.), doctors of podiatry (D.P.M.), and doctors of chiropractic (D,C.),
Massage Thcrallist means a person properly licensed to administer massages, when acting within the scope of their licenses, are deemed to be physicians.
pursuant to Chapter 480 of the Florida Statutes, or other states' applicable law.
Plan means this Master Plan of Benefits, including any Schedule of Benefits attached
Medically Necessary means treatment, care or services that are consistent with the hereto.
diagnosis, complies with acceptable medical standards, is not primarily for the
participant's convenience and is the most appropriate level of service which can Pre - existing Condition means any condition, physical or mental, for which medical
be safely provided. When applied to hospital inpatient care, it means that care advice, diagnosis, care or. treatment was recommended or received within the
cannot be safely provided on an outpatient basis. Care that has not received twelve (12) month period ending on the enrollment date.
federal approval will not be considered medically necessary.
Preventative Care means services and supplies ordered and /or provided by or under
Midwife means any person, other than a licensed physician or Certified Nurse the direction of a physician for which there is no medical diagnosis or does not
Midwife, who is state licensed to practice midwifery. seek to diagnose, treat, or cure a sickness or injury.
Midwifery means the practice of supervising the conduct of a normal labor and Reasonable Fee means the benefit allowances as determined by the Trust for all
childbirth, with the informed consent of the parent; the practice of advising the eligible expenses incurred by a participant. The basis will be the relative value
parents as to the progress of childbirth; and the practice of rendering prenatal studies and schedules utilized and evaluated by the Trust. The benefit
and postnatal care. allowances utilized by the Trust are determined by studies of charges for similar
benefits within a common geographical area. These studies are used to develop
New Employee means h employee who has never been previously employed by the benefit value schedules that are updated on a routine basis.
employer prior to the effective date of this Plan and who is employed by the
employer on or after the effective date of this Plan, or an employee who was Registered Graduate Nurse or Licensed Practical Nurse means a person duly
employed by the employer prior to the effective date of this Plan and was ineligible licensed by the state in which such person is engaged in the practice of nursing.
to participate in the employer's prior plan because the employee had not Rehabilitative Services means health care services for the purpose of which is to
completed the period of continuous employment with the employer as set forth, in restore functional defects.
such plan, if any, to qualify to participate in such plan.
Routine Care means services and supplies ordered and /or provided by or under the
state in which such person is engaged in the practice of occupational therapy and
Occupational Therapist means a person who is duly registered licensed by the direction of a physician for the purpose of the diagnosis, treatment, or cure of a who is a member of the American Occupational Therapy Association. sickness or injury.
Outpatient means a patient who has not been admitted to a hospital as an inpatient Second Surgical Ovinion means the second opinion contained in a written statement
and who has not been charged for room and board. on the necessity for the performance of a covered surgical operation given by a
board- certified specialist who, by the nature of the physician's specialty, qualifies
Participant means and includes the employee and any of his or her legal dependents the physician to consider the surgical opinion being proposed and who is not
covered under this Plan. Participant also means and includes those employees associated with the physician initially recommending the surgical operation.
and their dependents that qualify for continuation of coverage under COBRA.
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Fforlda Munl�surance Trost Medical Master Plan of Benefits Florida Municipal Insurance Trust Medieal Plan of Benefits
Service Provider means a state licensed person or organization providing services
deemed to be covered expenses under this Plan. Subject to the provisions of this Section for each participant under this Plan, the
' maximum liability of the Trust to such participant during the entire period such
Sickness means a bodily disorder, illness, or infirmity, which has been or is participant is covered hereunder shall be the amount specified in the Schedule of
diagnosed by a physician. Benefits.
Skilled Nursing Facility means a state licensed institution which provides 24 hour (1) If, at any time, benefits totaling at least $1,000 have become payable under
nursing care for a patient whose condition does not warrant hospitalization and this Plan to any participant, the maximum liability of the Trust with respect to
has been approved for payment by the Trust. The facility can operate such participant during the subsequent period such participant is covered
independently or as part of a hospital. under this Plan may be restored to the amount specified in the Schedule of
Benefits upon receipt and approval by the Trust of evidence of such
Total Disability means a medically determinable physical or mental impairment participant's insurability. Such restoration will not be made during a calendar
which renders a participant so incapacitated as to be unable to engage in any year in which expenses were incurred. Evidence of insurability must be
gainful occupation, within the range of his /her normal ability, and taking into furnished without expense to the Trust.
consideration education, training and work experience.
(2) If, during any one calendar year, more than $1,000 in benefits has become
Trust means the Florida Municipal Insurance Trust, its Trustees and individuals or payable on behalf of a participant, said participant shall automatically be
organizations designated by the Trustees to act on their behalf. j entitled to $1,000 in restored benefits commencing with the next succeeding
year, regardless of whether the amount in the Schedule of Benefits has been
reached.
Items (1) and (2) of this Section do not pertain to the specific lifetime maximums of
SECTION II — DEDUCTIBLES limited benefits.
Individual Deductible - In the event the participant shall incur expenses for covered
medical services on or after their effective date of coverage, benefits will be
provided as follows for such expenses (except for any amount in excess of the SECTION IV — MAXIMUM EXPENSE TO PARTICIPANTS
reasonable fee). Such expenses shall be subject to a deductible applicable under
this Plan, and as set forth in the Schedule of Benefits, for each covered When the covered expenses of a participant reach the amount specified in the
participant during each calendar year. Schedule of Benefits, subject to the coinsurance provisions, all further covered
Family Deductible - All covered participants within a family shall be subject to the expenses for that calendar year will be paid at 100% of the actual reasonable fees, up
maximum accumulative deductible as set forth in the Schedule of Benefits during to the Lifetime Maximum of the Plan.
each calendar year.
'i Deductible credit from employer's prior coverage - In the event a participant has
,I incurred and paid covered expenses during a calendar year under any other SECTION V — ELIGIBILITY AND ENROLLMENT
group health insurance plan issued to the employer which was in effect
immediately prior to the participant's coverage under this Plan, then the amount Commencement of Coverage - Subject to any waiting period set forth under this
of such covered and paid expenses shall be credited toward the participant's Plan and to any other condition of commencement expressed in this Plan,
deductible under this Plan for that calendar year. coverage hereunder shall commence as follows:
1 In the event
O an employer had no group health plan covering its employees and
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dependents in effect immediately prior to the effective date of this Plan, all
employees in the employ of such employer on the effective date of this Plan,
and their eligible dependents, except a dependent that is totally disabled or a
SECTION III — LIFETIME MAXIMUM AND RESTORATION OF dependent that has been exposed to the HIV infection or a specific sickness or
medical condition derived from such exposure, shall be eligible to participate
BENEFITS in this Plan. Coverage shall commence as of the effective date of the
Participation Agreement of the employer without proof of insurability provided
Each participant is entitled to the services listed below when incurred while the Plan the Trust receives a properly and accurately completed and executed
is in force and when necessary and consistent with the accident or sickness for which enrollment form and any required medical statement application no later than
the participant is being treated. 30 days following the effective date of the Participation Agreement. If
I
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Florida Municipal lnsuranca7rust Medical Master Plan of Benefit Florida Municipal Insurance Trust Medical Master Plan of Benefits
application is not received on or before the expiration of 30 days following the (1) Initial eligible p eriod - within 30 days of satisfaction of the Plan waiting
effective date of the Participation Agreement of the employer, any application period.
for coverage by an employee, or his eligible dependents, will be governed by
f the provisions set forth in Enrollment Paragraph (4). (a) New employees, and their eligible dependents, except totally disabled
P dependents and dependents exposed to the HIV infection or a specific
(2) In the event an employee, or eligible dependents, were validly covered under a sickness or medical condition derived from such exposure, shall be eligible
group health insurance plan issued to the employer and in effect immediately to participate in this Plan without proof of insurability, and shall commence
prior to the effective date of this Plan and such plan is discontinued and on the fast billing date following the eligibility requirements set forth above.
replaced with this Plan, all such employees and eligible dependents actually If the enrollment form is not received on or before the expiration of the
covered under such prior plan shall be eligible to participate iti this Plan, period set forth above, any application for coverage by a new employee or
without interruption of coverage and without proof of insurability, unless such their dependents will be governed by the provisions set forth in Paragraph
employee or dependent is entitled to any extension of benefits in accordance (4) of this section.
with S. 627.667, F.S., under the terms of the prior plan, and provided the
Trust receives a properly and accurately completed and executed enrollment (b) Except as otherwise provided in Commencement of Coverage Paragraph (2),
form, and any required medical statement application, no later than 30 days in the event an employee or eligible dependent is hospital confined, totally
following the effective date of the Participation Agreement of the employer. In disabled or otherwise disabled when coverage would otherwise begin,
the event such employee or dependent is entitled to an extension of benefits in coverage will begin the billing date of the month following the employee or
f accordance with S. 627.667, F.S., under the terms of the prior plan, such dependent's return to good health when able to perform the normal
4 employee or participant shall be entitled to participate in this Plan without activities of a well person of the same age and sex. This subsection does
interruption of coverage and without proof of insurability provided the Trust not apply to a newborn child of an employee covered for dependent coverage
regyes _finccpreltely completed and executed enrollment form, and any at the time of birth.
required medical statement application,'no later than 30 days following the
7 effective date of the Participation Agreement of the employer; however, the (c) In the event an employee's coverage terminates due to termination of
level of benefits under this Plan shall be no more than the applicable level of employment and such employee returns to full -time employment within
benefits. under this plan reduced by any benefits payable under the prior Plan. ninety (90) days, such employee's coverage may be reinstated without
completing the period of continuous employment set forth in the Employer's
Upon request, the employer, employee and dependent shall provide the Trust Participation Agreement, provided an enrollment form is received by the
such information as is reasonably necessary, including the prior plan, to Trust within thirty (30) days of the employee's return to employment. If the
coordinate the level of benefits payable under this Plan and the prior plan, for enrollment form is received more than thir ' 30 s
the Trust to verify the level of benefits provided under the prior plan, and to ( ) da y after the employee's
determine each employee and dependent who was validly covered under the return to employment, any application for coverage will be governed by the
rovisions set forth in Paragraph (4) of this section.
prior plan on the date of discontinuance of the prior plan. If application is not p
received on or before the expiration of 30 days followi the effective date of
p� y g (d) In the event an employee was covered under this Plan through another
the Participation Agreement of the employer, any application for coverage by employer within thirty (30) days prior to beginning employment with this
an employee, or his eligible dependents, will be governed by the provisions set employer, such employee will not be required to complete the period of
forth in Enrollment Paragraph (4). continuous employment set forth in the Employer's Participation
Agreement, provided an enrollment form is received by the Trust within
'd Eli ig_biH - Employees and eligible dependents shall be eligible for coverage on or thirty (30) days of beginning employment with this employer. Required
after the effective date of this Plan if: contributions must be paid at the new employer's rates from the prior
P billing date for reinstatement of continuous coverage. If the enrollment
'j (1) They, fall within the classification set forth in the Employer's Participation form is received more than thirty (30) days after the employee's return to
II I Agreement; and employment, any application for coverage will be governed by the provisions
�I I (2) They have completed the period of continuous employment with the employer set forth in Paragraph (4) of this section.
as set forth in such classification.
(e) Pre - existing limitations will apply, as outlined in Section X.
An employee shall not be eligible as a dependent under the same employer group
except when both spouses are eligible employees and desire dependent children) (2) Open enrollment period - within 30 days of the Plan's policy renewal
li! coverage. In that case, one employee may cover the sppuse and children as anniversary. Eligible employees can enroll in the Plan or terminate coverage
I{ dependents for health benefits and the spouse may be covered as a single during the open enrollment period. Pre- existing limitations will apply,' as
employee for other employee coverage(s). outlined in Section X. If application is received 30 days or more following the -.
Plan's policy renewal anniversary, any application for coverage by an employee
Enrollment - Employees and eligible dependents may enroll for coverage under the or eligible dependents will be governed by the provisions set forth in Paragraph
Plan by completing and submitting to the employer an accurately completed and (4) of this section.
executed enrollment form provided by the Trust, as specified below:
— UdmotlleWw Ambd MtheSeledideafft"b (7/98) Page '•UrAm othe Wn sfebd In the Schedule d Benellh(7 /9e)
2< &
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Florida Munladdlillinsurance Trust Medical Master Plan of Benefits . Florida Municipal Insurance Trust Medlealildhir Plan of Benefits
ow
(3) Speaal enrollment period - within 30 days of certain events or loss of coverage accompany the employee's supplemental application for coverage for
as outlined below: such child. As a condition of continued coverage, the employee shall
(a) de eligible employee and/or eligible dependent except totally disabled adoption upon its entry and the employee shall, upon request, provide to
dependent or a dependent exposed to the HIV infection immediately provide the Trust with a certified copy of the judgment of
on or a specific the Trust, under oath, such information as is reasonably necessary to
sickness or medical condition derived from such exposure, was: keep the Trust apprised of the stage of the adoption proceeding.
® covered under another health benefit plan as an employee or dependent,
or COBRA continuation of coverage at the time of initial eligibility to
enroll for coverage under this Plan, and ® In the event of an adoption or placement for adoption (other than
® newborn), legal guardianship or court order, the effective date of When offered coverage under this Plan at the time of initial eligibility coverage shall be from the date of the child's placement in the
reason for
stated, o writing, that coverage under another health plan was the employee's residence or date specified by court order. If application is
r declining enrollment, and not received within thirty (30) days of the effective date, the Trust
(D Demonstrated that loss of coverage under an individual or group health reserves the right to charge an additional premium for coverage of such
benefit plan occurred within the past thirty (30) days as a result of legal child(ren) from the effective date to the date of receipt of application. As
separation, divorce, death, termination of employment, or reduction in a condition of coverage, the employee shall provide the Trust with a
the number of hours of employment, and certified co of the judgment of adoption, gu ardia n s hip PY ] !� p , gu an hip or court order.
O Requests enrollment within thirty (30) days after the termination of (d) Pre - existing limitations will apply, as outlined in Section X.
coverage under another health benefit plan.
(4) Those eligible employees who refuse coverage for themselves or their eligible
P Y
(b) An individual who loses coverage as a result of termination for failure to a dependents under this Plan, those employees applying for coverage, including
premiums /prepayment fee on a timely basis, or the discontinuance of any dependent coverage, under this Plan subsequent to the effective date of the
contributions toward the health coverage plan by the employer, or for cause Participation Agreement of the employer, or those employees and dependents
does riot have the right to special enrollment under this Plan. Voluntary who do not satisfy the coverage provisions specified in Paragraphs (1), (2), and
termination of coverage does not constitute loss of eligibility of coverage. (3) of this Section may apply for coverage at a later date by medical statement
I' application. Such employee, on behalf of himself /herself or his /her
(c) A newly eligible dependent, except a totally disabled dependent or a dependents, shall provide the Trust with a completed medical statement
dependent exposed to the HIV infection or a specific sickness or medical application and such applicants shall be subject to the applicable rules and
condition derived from such exposure, as a result of marriage, birth, regulations of the Trust. The Trust will review all medical statement
adoption or placement for adoption, legal guardianship or court order, applications and provide the eligible employee's employer with a notice of
without proof of insurability provided the Trust has received an accurately
completed and executed enrollment form, within thirty (30) days of the acceptance or notice of rejection. If accepted, the effective date of coverage for event. Eligible dependents may only be enrolled i such applicant shall be the first day of the month following the receipt of
the eligible dependent is notice of such acceptance. Pre - existing limitations will apply, as outlined in
a dependent of an employee who is already partici pating in the Plan. If the Section X.
employee fails to apply within the thirty (30) day period, any application for
�I coverage will be governed by Paragraph (4) of this Section. The employer shall submit such form and any required medical statement
p ® In the event of marriage, the effective date of coverage shall be the first application, together -with any contribution due to the Trust, as a prerequisite to
I� day of the month following receipt of notification by the Trust. the coverage of such employee or dependent under this Plan.
t ® In the event of a newborn, coverage will take effect on the date of birth
and will continue for thirty (30) days. Coverage beyond this period Certificates of creditable coverage, as specified in Section X, should be provided at
requires the enrollment form as specified above. If application `is riot the time an application for enrollment is made by the eligible employee and their
received during this time period, the Trust reserves the right to charge eligible dependents.
it an additional premium for coverage of such newborn from date of birth
to the date of receipt of application or the end of the thirty (30) day The employer does not act as an agent of the Trust in the enrollment and
period. withdrawal of its employees and their eligible dependents. Notwithstanding, and
m in addition to, any other conditions expressed herein for coverage or payment of
In the event of an adoption of a newborn child, if a written application to
adopt a newborn child has been entered into by the employee prior to benefits and services, coverage for each employee and eligible dependents under
the birth of the child, such child shall be subject to the conditions and this Plan shall commence no earlier than the first day of the month immediately
following the date on which the Trust has actually received a properly and
entitled to the benefits and services provided in this Plan applicable to accurately completed and executed enrollment form and any required medical
newborn children provided the child is ultimately adopted pursuant to statement application and the contribution attributable to the particular
Ch. 63, F.S. As a condition of coverage, the written agreement shall employee and eligible dependents.
i
j •• udea ogwAostdhdmtMSdm "GfBmNts Page 10 •* u o4n6tlwMw snmdmmoscnddm.ofamems Page 11
Florida MunL91111111111Mnsurance Trust Medical Master Plan of Benefits • Florida Municipal Insurance Trust Medicadilker Plan of Benefits
SECTION VI - COVERED EXPENSES connection with proven malignancies or for radium, radon or isotope therapy.
(9) Obstetrical Care ** - Maternity benefits will be provided to participants,
If the employer and the participant have satisfied the terms and conditions provided subject to the same limitations and exclusions applied to as all other benefits provided under this Plan; provided, however, dependent children shall not be
in this Plan for coverage and for the payment of benefits and services, the participant entitled to maternity benefits. Complications of pregnancy (excluding false
is entitled to the benefits and services listed below when incurred while the Plan is in labor, occasional spotting, prescribed rest, morning sickness, hyperemesis
force and when medically necessary and consistent with the accident or sickness for gravidarum, pre- eclampsia and similar conditions not constituting a
which the participant is being treated. The Trust will pay the reasonable fee for such nosologically distinct complication) are eligible for benefits on the same basis
benefits and services and, all such benefits and services unless otherwise ex r '1
p ess y as any other illness.
provided herein, shall be subject to any calendar year deductible and /or coinsurance
shown on the Schedule of Benefits. (10) Newborn Care - Eligible hospital services as provided herein for participants
shall also be provided for a newborn dependent child of a participant from
Pre- Admission Certification - All non - emergency hospital admissions must be: the moment of birth and shall include mentally diagnosed congenital defects,
birth abnormalities or rematuri
certified seven 7 days prior to a 1 A newborn infant of a dependen
( ) () Y p panned admission; eligible and shall be covered so long as the dependent child is covered c hil d der
(2) certified. within 48 hours or the first working day after the admission. the provisions of this Plan but not to exceed eighteen (18) months.
Failure to obtain certification will result in a 20% reduction of benefits paid. Ph ician Services - The I'' ys expenses incurred for the following physician services will
h? Pre- admission certification is not required for the birth of a child, provided the be paid as stated in the Schedule of Benefits (in excess of any deductible and/or
coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the
hospital or birthing center length of stay does not exceed: end of the calendar year whichever first occurs.
(1) 48 hours following,a vaginal delivery, or (1) Surgical Services - wherever performed, limited to operative procedures for
(2) 96 hours following a cesarean delivery. the treatment of accident or sickness.
The surgical al allowance includes post-
�
�I. Inpatient Hospital Services The expense incurred for the following services will be
operative treatment.
h paid as stated in the Schedule of Benefits (in excess of any deductible and /or (2) Surgical Assistant - provided the assistance is medically necessary, no intern,
coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the resident, or other staff Physician is available, and the condition of the patient
end of the calendar year whichever first occurs. and the type of eligible surgery performed require such assistance.
(1) Hospital room and board up to but not to exceed the average semi- private (3) Consultations - which are medically necessary due to complications,
room rate. ** complexity or different diagnosis. A consultation report must be part of the
hospital medical records.
(2) Intensive care unit (including cardiac and neonatal care units) not to exceed
q three (3) ** times the average semi- private room rate. (4) Anesthesia Administration - when rendered in connection with a covered
(3) Progressive care unit up to but not to exceed one and one -half (P /2 ) times the surgical or obstetrical ** procedure. -
average semi - private room rate only if incurred immediately following a (5) Obstetrical Care ** - this expense will be considered incurred at the
confinement in an intensive care unit. termination of the pregnancy. Dependent children shall not be entitled to
(4) Miscellaneous services and supplies provided such as operating and recovery
maternity benefits.
? room charges, x -ray and other diagnostic procedures, laboratory tests, (6) Professional Component Expenses - of radiology, pathology and laboratory.
pathological services, medications and dressings. (7) Medically Necessary Hospital Visits - not including post - operative treatment.
(5) Transfusion supplies and services including blood administration expenses (8) Medically Necessary Care - rendered outside of the hospital. Routine
but not including blood, blood plasma and /or blood derivatives unless physical examination expenses are not covered, unless otherwise therwise s ecificall Y
otherwise s P
specifically stated in this Plan.
Y
stated in the e Schedule of Benefits.
Anesthesia services, including supplies, equipment and h physician's charges 9
(6 ) A i g PP P Y g Dental Care and d Treatment - rendered by a physician or dentist within nine
thin
for regional, intravenous, halation, traspinal and caudal anesthesia
P Y �'
inhalation,
(90) days of an accident when, as the result of the accident, natural teeth
services when performed by a regular salaried hospital employee and when have been damaged or fractured or a dislocated jaw requires setting.
performed in connection with surgical, obstetrical * *, electro- shock, or dental
services ** covered **
eyed under this Plan. 0 Concurrent Care - combining medical ( ) ical sur 'c
g al and obstetrical care wher eby
th e Trust will - care
a for necessary eligible ble medical
pay m'Y gl medical, 'cal or obstetrical
7 ,
i�
() Oxygen therapy, diathermy and physiotherapy. and necessary eligible surgical obstetrical ** care in addition to other eligible
(8) Roentgenologic (x -ray) and cobalt bomb therapy when such therapy is in medical expense during a single hospital confinement.
••Unless othenvi:a stated "a Schedule of BaaaBts (7/98) Page 12 '•udassotliawlsasfaYd M tha8elxdab meenems (7/98) Page 13
Florida Munl 1119&urance Trust Medical Master Plan of Benefits Florida Municipal Insurance Trust Medicajftr Plan of Benefits
(11) Well Child Care - the reasonable fees charged by a physician for physicals, approval must be obtained by the Trust for prosthetics and other devices
examinations, developmental assessments, anticipatory guidance, which exceeds $500 in cost.
immunizations and laboratory tests, in keeping with prevailing medical
standards, which are not required for the treatment of illness or injury, for (5) Initial Eye Glasses or h Contact Lens - resulting only from cataract or glaucoma
covered dependent children from the moment of birth to sixteen (16) years of
surgery (including those surgically implanted).
age, are payable subject to the following: (6) Hospital Charges - for emergency.room care or for surgical services performed
(a) A lifetime maximum of eighteen visits at ,the following age intervals; birth, in the outpatient department of a hospital.
two months, four months, six months, nine months, twelve months, (7) Alternative Housing - in close proximity to a medical facility located in the
fifteen months, eighteen months, two years, three years, four years, five state:
years, six years, eight years, ten years, twelve years, fourteen years and
sixteen years. (a) If the Trust finds a bone marrow transplant otherwise covered under the
(b) Benefits are limited to one visit payable to one physician for all service terms of this Plan has been performed on the participant at the medical
provided at that visit, facility;
(c) The benefit is not subject to the calendar year deductible, but is subject (b) Due to the special nature of the bone marrow transplant procedure, it
can be performed in no more than four medical facilities in the state the
to the coinsurance, if applicable. participant does not reside within 45 minutes driving time to the medical
(12) Therapeutic Treatment - by a radiologist including radium, radon, isotope, x- facility;
ray and cobalt bomb therapy when in connection with proven malignancies. (c) Due to the special nature of the bone marrow transplant procedure, it is
I t (13) Newborn Care - when rendered by a physician to a newborn dependent child medical necessary for the participant to remain over a prolonged p eriod of
of a participant, from the moment of birth, for covered injury or sickness, time in close proximity to the medical facility in which the procedure was
including necessary care or treatment of medically diagnosed congenital performed in order to closely monitor potential post - procedure
y , defects, birth abnormalities, or prematurity. A newborn infant of a complications directly related to the procedure;
deep ndenf "i6 i d"is` "eligibre 'and'shaM be` covered so long as the dependent (d) The costs of the physician- directed inpatient hospital stay would far
child is covered but not to exceed eighteen (18) months. outweigh the cost of outpatient services combined with the alternative
housing.
Other Medical Services - The expenses incurred for the following services will be (e) The above findings and decisions to permit alternative housing, including
paid as stated in the Schedule of Benefits (in excess of any deductible and /or those related to medical necessity, and the type, location, cost, length of
coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the stay and nature of the alternative housing, shall be within the sole
end of the calendar year whichever first occurs. discretion of the Trust. The fact that a physician may prescribe, order,
(1) Emergency Professional Ambulance Service - to the nearest hospital able to recommend, or approve the alternative housing does not of itself make it
I' provide the care required for the patient. Transportation costs of a newborn medically necessary or make the expense an allowable expense.
to and from the nearest available facility appropriately staffed and equipped (f) Notwithstanding the other terms, conditions and limitations provided in
to treat the newborn's condition, when such transportation is certified by the this subsection, the Lifetime Maximum under this section is $10,000 * *.
attending physician as necessary to protect the health and safety of the
newborn child shall be covered. The coverage of such transportation costs Supplemental Accident Benefit - Services under this Plan will be provided, as stated
shall not exceed the reasonable fees, and in no event shall exceed the sum of in the Schedule of Benefits, for each accident when expenses are incurred, as the
fi $1,000. ** result of an accident for medical, surgical, and hospital care and treatment,
2 Prosthetic and Other Devices - initial under this Plan appliances, crutches, within ninety (90) days subsequent to an accident not connected with
Iri O ( ) PP � q
braces, cardiac pacemakers, standard model wheelchair, or other mechanical employment and when such treatment has been prescribed by a physician.
appliances medically necessary for the correction of conditions arising out of
!il injuries or sickness, provided the equipment is prescribed by a physician, Expenses which are incurred after the ninety (90) day period or after the
and the equipment does not, in whole or in part, serve as a comfort or maximum for each accident has been reached, will be paid as regular Plan
convenience item. Written approval must be obtained by the Trust for benefits, subject to the deductible and /or coinsurance provisions of this Plan.
prosthetics and other devices which exceeds $500 in cost. The Trust shall
have the right to buy or rent such appliances as they may elect. Diagnostic X -ray. Laboratory and Pathological Services - Services for outpatient
hospital and physician charges for diagnostic x -ray, laboratory and pathology
(3) Splints, Casts, Trusses. required for the treatment of an illness shall be
q paid in accordance with the
(4) Other Durable Medical Equipment Rental - required for temporary therapeutic, schedule of benefits.
provided the equipment is prescribed by a physician, and the equipment does
not, in whole or in part, serve as a comfort or convenience item. Written Chiropractic Services - The reasonable fees for chiropractic services shall be
covered, subject to all Plan provisions, deductibles and coinsurance.
•'unimou ndses"dIndmSehodu'ofBomft(7 /98) Page 14 -* LWm otlnndsss "dInB183dmduMoferne'(7/98) Page 15
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Floft�lclpal Insurance Trust Medical Master Plan of Benefits • Florida Municipal Insurance Trust Medlcamakr Plan of Benefits
1W
(3) the range of charges for services that will or could be rendered. mastectomy.
Hospice care benefits are for reasonable fees incurred for the palliation or
management of terminal illness. Benefits shall be payable for the routine home Mammogram Benefit - The reasonable fees for mammogram testing, breast cancer
care, and continuous home care subject to a Lifetime Maximum of $6,000 " *, for a screening or diagnostic services, and health testing services utilizing radiology
maximum period of six (6) months. Hospice care will only be approved once for a equipment (registered with the state's Department of Health and Rehabilitative
participant. Services) for breast cancer screening shall be covered, and according to these
guidelines:
TMJ Benefit - The reasonable fees charged by a hospital, dentists, or physicians for (1) One baseline mammogram for women ages 35 to 40;
the treatment of temporomandibular joint dysfunction are eligible for benefits up
to a Lifetime Maximum of $1 ** for all services related to'this condition. Only (2) One mammogram every 2 years, or more frequently if prescribed by the
one $1,500. ** lifetime benefit will be provided. participant's physician, for women ages 40 to 50;
(3) One mammogram, every year for women 50 years of age and over.
Cardiac Rehabilitation Benefit - Service of a state licensed cardiac rehabilitation
facility for cardiac rehabilitation on an outpatient basis up to a Lifetime Maximum Heart, Heart-Lung, Bone Marrow, Cornea Tissue, Kidney and Liver Transplant
of $2,000 ** provided such services are prescribed by a physician and provided Benefits - The reasonable fees for inpatient hospital and physicians services
under the direct supervision of a physician. A participant who is eligible for this associated with a heart, bone marrow, cornea tissue, kidney or liver transplant
benefit must meet the following criteria: provided the participant meets objective criteria set forth by the medical industry
(1) Myocardial Infarction - post myocardial infarction patient may enter the for the tissue or organ transplant, the transplant procedure is performed in a
program anytime, at the discretion and referral from Physician; facility duly licensed to facilitate the procedure by a physician duly credentialed to
(2):. Post op Cardiovascular Surgery -a minimum of three weeks aorta -coronary
perform the transplant, the procedure is approved by the U.S. Food and Drug
bypass surgery, or discretion and referral from physician; Administration, the transplant tissue or organ is donated to the participant and
not purchased through an outside agent, and the transplanted tissue or organ
(3) Adequate control of complications,_ i.e., angina, congestive heart failure or
originated from a human being and not from cadavers, animal laboratories, or
arrhythmias; other experimental sources.
(4) Pacemaker patients with any of the above diagnosis and /or decreasing
functional capacity. Due to the extensive nature of the services related to transplantations, a pre-
! determination must be obtained from the Trust.
Home Health Care Benefit - The reasonable fees, up to a maximum calendar year
benefit of $1,000, incurred for home health services performed by a home health
agency resulting from an accident or sickness to a participant while this Plan is in
force shall be covered, subject to all Plan provisions; provided the services are SECTION VII - HOSPITAL BILL SELF -AUDIT
performed pursuant to a written plan of treatment prescribed by a physician that
is approved in advance by the Trust. The Trust will provide a payment to the participating employee in the amount of 50%
of the savings (the total dollar difference between the original bill and the revised bill),
Skilled Nursing Facility Benefit - Services and supplies provided under the direction not to exceed $1,000.
of a physician, provided the services are performed pursuant to a written plan of
treatment prescribed by a physician that is approved in advance by the Trust. The employee will receive a payment from the Trust for any errors that the employee
identifies and the hospital corrects.
Mastectomy :Benefit - The reasonable fees for inpatient hospital and physician
services `associated with the surgical removal of all or a" part of the breast if The following steps must be taken by the participant before contacting the Trust:
determined medically necessary by a licensed physician, prosthetic devices, and (1) Obtain a copy of the itemized bill before leaving the hospital or make
reconstructive surgery incident to the mastectomy; shall be covered, and subject
to the following conditions and limitations: arrangements for an itemized bill to be sent to you.
(2) Review the hospital bill for overcharges or errors on the bill.
(1) Coverage for prosthetic devices and reconstructive surgery shall be limited to (3) If the participant feels an error was made, the business office of the hospital
the initial prosthetic device and initial reconstructive surgery incident to the
must be contacted to review the possible error(s).
mastectomy;
If the mastectomy reveals no evidence of mal (4) Request the business office of the hospital to satisfactorily explain the
(2 ) y gn cy, coverage for prosthetic i
devices and reconstructive surgery incident to the mastectomy is limited to i possible error(s) or issue a revised bill, which contain the credit(s) for the
an initial prosthetic device provided, and to medically necessary incorrect charge(s).
reconstructive surgery performed, within two (2) years of the date of the (5) Send the revised bill to the Trust with a letter outlining your actions, the
••uM...omarr...re.du�m.su.ea a.aeenen�sir /ss) Page 18 Page 19
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the State of Florida for the purpose of insuring a group of individuals; (41) Services or supplies for injuries sustained or sickness contracted while in
(b) Any plan, program or insurance policy, and /or PIP automobile insurance any military force of any country while such country is engaged in war or
as required and defined in the Florida Statutes, which provides benefits or hostilities (whether or not declared), or while performing police duty as a
makes payments to or on behalf of a participant for hospital, medical member of any military organization.
and /or other health care expenses; (42) Services or supplies for injury or illness that results from deliberately and
,m- (c) any group contract issued to this Trust; voluntarily undertaking activities that subject the participant to unnecessary
exposure to danger or unnecessary exposure to obvious risk of injury. This
(d) Any coverage under a plan or a law of any federal, state or local exclusion shall not apply to services or supplies for injury or illness resulting
government or any political subdivision thereof, including but not limited from the artici ant's
'i a under Medicare, and/or an other federal; state or local P P Participation in sponsored sporting events or
to, coverage / Y traditional recreational activities.
government- sponsored program or programs, unless otherwise provided
by law; ( 43 ) Services or supplies complications, which result from or arise out of the
PP has for P
provision of services or supplies that are excluded under this Section.
A participant shall have no right to benefits under this Plan if said
participant elects to waive any entitlement to benefits provided under any (44) Fees in excess of the percentage specified in the Schedule of Benefits, or in
plan described in this paragraph. The participant shall provide, execute and excess of reasonable fees.
deliver such information, instruments and papers, and do whatever else is
necessary to secure the instruments and papers, and the Trust's rights under Benefits payable under this Plan will be limited to services provided and expenses
this paragraph. incurred within the continental United States. Any expenses incurred by a
participant outside the continental United States will be subject to approval by the
(31) Expenses that are covered under Parts A and B of Medicare, if the participant Trust.
is not an active employee or the dependent of an active employee.
(32) Treatment and /or drugs received in a veterans hospital or government facility
due to a service connected disability.
(33) Any service or supplies provided before coverage begins or after coverage SECTION IX - COORDINATION OF BENEFITS
terminates, for the group or for the participant, except to the extent and in
the manner provided by Florida law and in the manner rovided under
P The purpose of health care coverage is to help meet actual expenses. In line with that
Sections X, XIII, XIV and XV. purpose, this Plan contains a non -profit provision coordinating it with other plans,
(34) Personal comfort articles such as beauty and barber services, radio, and including group plans under which a participant is covered, so that the total benefits
television. available will not exceed 100% of the allowable expenses.
gl (35) All other services or supplies not furnished by a hospital for inpatient and /or Primartr Coverage - A plan without a coordinating provision is always the primary
outpatient treatment or specifically listed as covered expenses. plan. If all plans have this provision:
(36) Discounts applied to total expenses by health care providers will not be used
(1) the plan covering the person as an employee rather than as a dependent is
to satisfy deductibles or coinsurance under this Plan. primary.
(37) Any treatment for injury or sickness which a contributing cause was the
(2) the plan covering the person as an active employee or as a dependent of an
participant's commission of, or attempt to commit, a felony, or the par_ ticipant active employee rather than Medicare is primary;
being engaged in any illegal act.
k (3) if a child is covered under both parents' plans, the plan for the parent with
I
(38) Preexisting conditions, except to the extent and in the manner provided in
Section X. the earliest birthdate in the calendar year is primary;
ill " (4) if a dependent child is covered under both parents' plans, and both parents
(39) Services or supplies for any occupational condition, ailment or injury arising have the same birthday, the plan which has covered the parent for a longer
out of or in the course of employment for wage or profit or any other endeavor
period of time is primary;
for potential profit or gain, or services which are furnished to a participant
under the laws of the United States or any state or political subdivision a (5) if a dependent child is covered under both parents' plans, and the parents
thereof, for which the participant shall have no right under this Plan, even are divorced or separated, the primary plan will be determined in the
though the participant elects to waive that right to such benefits or service. following order:
7,
"' (40) Services or supplies for injury or illness resulting from suicide or attempted Furst, the plan of the parent with custody of the child;
suicide, self - inflicted injury or self - induced illness, whether sane or insane. Second, the plan of the spouse of the parent with the custody of the child;
This includes participation in and /or incitement of an altercation. and
• Third, the plan of the parent not having custody of the child;
uruau es:..roea m ms seoeawe ota.�ena R /ss) Page 22 sonwnarue.eeo mm.senmme aeen.ne p /se) Page 23
P _
ill Flo niclpal.InsurancoTrust Med Master Plan of Be neflts • Florida Municipal Insurance Trust Medic_ter Plan of Benefits
unless the specific terms of a court decree state that one of the parents is dependents who enroll in the Plan during the initial enrollment period, and
responsible for the health care expenses of the child in which case the plan
(2) fora 12 month period beginning on the effective date for employees and their
covering such parent is primary. A copy of the court decree must be dependents who enroll in the Plan during the open enrollment period and the
furnished to the Trust; special enrollment period.
it (6) The Plan covering an employee, or the employee's dependents, rather than a All participants enrolled subsequent to the effective date of this Plan will be subject to
GI' retiree, or the retiree's dependents, is primary;
i l this pre - existing condition limitation, except newborn or adopted dependents that are
(7) The Plan covering a person as an employee who has not retired, or the properly enrolled in accordance with this Plan.
l' employee's dependents, rather than the plan covering a person, or the Credit will be given for the time an eligible participant was covered under previous
person's dependents, as a retiree, is primary; coverage, if the previous coverage was similar to or exceeded the coverage provided
i 8 The Plan covering a person as an employee, or the employee's de dependents, under this Plan and the a was continuous to a date not more than 62 p revious covers
O g P P P g
l rather than a plan covering the person, or the person's dependents, under days prior to the participant's effective date of coverage under this Plan, exclusive of
COBRA, shall be primary. any waiting period under this Plan.
If none of the above rules apply, the plan that covered an employee or dependent The eligible participant may prove periods of prior health coverage by providing a
for a longer period of time is primary. certificate of creditable coverage, which includes periods of coverage and benefit
coverage levels.
Secondary Coverage - Services and benefits under this Plan will be coordinated with,
No pre - existing limitation will apply for an eligible participant presenting a certificate
and this Plan is hereby deemed secondary to plans providing coverage for of creditable coverage indicating continuous coverage similar to or exceeding the
services, supplies or benefits famished to a participant or paid under any of the
coverage provided under this Plan, if the previous coverage was more than 12 months
following plans of insurance coverage: with no more than a 62 break in coverage prior to the participant's effective date of
(1) any plan, program or insurance policy providing benefits for hospital, medical coverage under this Plan, exclusive of any waiting period under this Plan.
and /or other health care expenses under a group master policy including, but
not limited to, policies issued to any health maintenance organization or any
entity to which such policies may legally be issued in the State of Florida for
the purpose of insuring a group of individuals; SECTION XI - TIME OF PAYMENT, GRACE PERIOD
(2) any plan, program or insurance policy and /or PIP automobile insurance as
required and defined in the Florida Statutes, which provides benefits or makes All contributions are due and payable on the first day of each month for which
payments to or on behalf of a participant for hospital, medical and /or other coverage under this Plan is provided. If the employer fails to pay the contributions to
health Gaze expenses; the '[Must within twenty 20 days after the become due and
t1' ( ) Y Y payable, the Plan is
(3) any group contract issued to this Trust; automatically terminated effective the first day of the month in which such
it
(4) any coverage under a plan or law of any federal, state or local government or contributions were due and payable; no participant shall thereafter be entitled to any
�t further benefits hereunder.
any political subdivision thereof, including but not limited to, coverage under
Medicare and /or any other federal state or local government- sponsored
program or programs, unless otherwise provided by law. In the event this Plan terminates for any reason, the employer shall be liable for all
„h contributions due and unpaid as of the date of termination in the event that claims
(5) A participant shall have no right to benefits under this Plan if said participant were paid after the contributions became due and payable.
elects to waive any entitlement to benefits provided under any plan described
in this paragraph. The participant shall provide, execute and deliver such The Trust must give an employer forty -five (45) days written notice of any change in
Fj II information, instruments and papers, and do whatever else is necessary to the monthly rate of contribution or any changes in this Plan's terms or benefits.
secure the instruments and papers, and the Trust's rights under this
paragraph.
SECTION XII - CONDITIONS FOR RENDERING SERVICE
SECTION X - PRE - EXISTING CONDITIONS LIMITATIONS
The participant shall present proper identification issued by the Trust when applying
There is no coverage under this Plan for services or supplies to treat a pre - existing for hospital, physician, pharmacy or other medical services covered under this Plan,
condition or conditions arising from a pre - existing condition, until the participant has
The Plan does not confer upon the Trust or an ho an
been continuously covered under this Plan: P y p y rights to select a
physician for the participant. The participant shall be at liberty to elect his or her
(1) for a 12 month period beginning on the date of hire for employees and their
i
••Unme"M "shod lnaw,sdMU186f8mMb(7 /98) Page24 �; ••(NUa.dNnN�n Sehntlul®Manmsb(7 /ss) - Page 25
Flor1111111111aicipat:InsuranceTrust Medical M aster Plan of Benefits • Florida Municipal Insurance Trust Medl"r Plan of Benefits
—
physician, provided such physician is acceptable for practice in the hospital to which provided under Section I - Dependent.
the participant is admitted. Nothing contained herein shall interfere with the ordinary (5) Coverage of the employee, and spouse and dependents of an employee shall
relationship between the participant and the physician selected by the participant. automatically cease upon the employee becoming entitled to the benefits
Some employers may elect to make special arrangements with specific providers provided under the Title XVIII of the Social Security Act (Medicare).
and /or Preferred Provider Networks. If an employer makes such an arrangement, the
arrangement must be submitted to the Trust and benefits under such an agreement (6) Subject to the provisions of Paragraphs (1) and (2) of Section III, the coverage
will be paid on such terms and conditions as are agreed to in writing by the employer of any participant shall terminate automatically when the maximum benefits
and the Trust. for which such participant is eligible have been paid. Coverage for any
i remaining family participants shall, unless otherwise terminated in
The Trust does not undertake to furnish any services, but merely to pay for services to accordance with provisions hereof, continue so long as payment of required
the participant to the extent herein specified. The Trust shall not, in any event, be contributions is timely made.
liable for any negligence, misfeasance, nonfeasance, malfeasance, malpractice or any
A certificate of creditable coverage will be issued to all participants whose coverage
act of commission or omission on the part of any physician, hospital or other service
terminates. The certificate will be sent by First Class Mail to the participant's last
provider or the agent or employee of any physician, hospital or other service provider. known address. In addition, the Trust shall issue a certificate of credible coverage to
a,participant upon request, for up to 24 months following the end of the participant's
SECTION XIII - EMPLOYER'S TERMINATION AND RENEWAL coverage under this Plan.
Except as provided in Section XI, this Plan may be terminated by either party hereto _
Conversion Privileee Termination of EUs bi illity
by giving not less than forty-five (45) days written notice of termination to the other. (1) A participant whose coverage under this Plan is terminated for any reason
This Plan shall continue in force from month to month unless terminated pursuant to - and who has been validly and continuously covered under this Plan for at
the foregoing provision. least three (3) months immediately prior to such termination shall be entitled
to purchase a converted policy. The participant must apply to the Trust for
Except as hereafter provided, coverage for all employees and their dependents covered the converted policy in writing and must pay the first premium attributable
4` under this Plan shall automatically terminate immediately on the earliest of the to the converted policy within thirty -one (3 1) days of the date of termination.
following dates: The premium for such policy will be determined with premium rates
applicable to the age and class of risk of each participant that is to be covered
(1) On the date coverage under this group plan with an employer is terminated. under the policy and to the type and amount of coverage provided, however,
(2) On the expiration date as provided in Section XI, if the employer fails to make in no event shall such premium exceed 200 percent of the standard risk rate
'l the required contributions. as established by the Florida Comprehensive Health Association, adjusted for
differences in benefit levels and structure between the converted policy and
All claims must be submitted no later than ninety (90) days after the date of the policy offered by the Florida Comprehensive Health Association. The
termination of the policy in order to be eligible for payment. converted policy will be issued without evidence of insurability and will be
effective on the day following the termination of coverage under this Plan.
O 2 A participant is not entitled to a converted p ol i cy:
SECTION XIV - PARTICIPANT'S TERMINATION OF COVERAGE r r
(a) If termination is the result of the participant or employer's failure to
Unless a participant qualifies for and elects continuation of coverage pursuant to and timely pay a required contribution.
1:4111 in the manner provided in Section XV of the Plan: (b) If any discontinued coverage under this Plan is replaced by similar group
(1) Coverage for aarticipant shall terminate automatically at the end of the coverage within thirty-one (3 1) days of the date of termination of this Plan.
II ny p (c) If the participant is covered or eligible to be covered by Medicare.
month for which payment of the contributions specified herein shall have
been made by the employer for such participant. In the event the employer (d) If the person is covered or eligible to be covered under a group policy or
notifies the Trust that the coverage of such participant under this Plan is to i similar benefits are available to the participant under state or federal law,
be terminated. and the coverage or benefits, when combined with the benefits of the
(2) Coverage of the spouse of an employee shall automatically cease upon a legal separation converted policy, will result in the participant's overinsurance.
of the spouse and employee or termination of the marriage between the spouse and - {3) .The.., terms and coverage conditions in and benefits provider under the
employee. converted policy will be designed to comply with S. 627.6675, F.S., and the
(3) Coverage of the spouse and dependents of an employee shall automatically cease upon terms of S. 627.6675, F.S., shall prevail to the extent of any conflict with the
the death of the employee. terms of this Plan.
cease as
(4)- The converted policy may be issued by an authorized insurer selected by the
f employee hall automatically a e
4 Coverage of a dependent child o an m to s au
O g P Y Y
Trust to provide conversion coverage.
•• U�dmobw kastd dinU*ScheddeMBam t (7/98) Pe e26 ' a�eMe■s�nwr.orB«aebIU98) Pe e27
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Flonidpal Insurance Trust Medical Master Plan of Benefits • Florida Municipal Insurance Trust ModiciMter Plan of Benefits
Now
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SECTION XV — CONTINUATION OF COVERAGE - COBRA (3) Notice hereunder to employees or qualified beneficiaries shall be by First
Class Mail to their last known address; notice to the Trust shall be by First
The Plan provides an election for continuation of coverage to qualified beneficiaries Class Mail to the Board of Trustees of the Florida Municipal Insurance Trust.
who would otherwise lose coverage under the Plan as a result of a qualifying event.
A qualified beneficiary means the covered spouse or dependent child of a covered A qualified beneficiary's election of continuation of coverage must be made within
employee who is a participant in the Plan on the day before the qualifying event. In sixty (60) days following notice to the qualified beneficiary. If the qualifying event is
the case of termination, the term also includes the covered employee. One exception termination, the covered employee's election of continuation coverage shall be deemed
to this rule is when a child is born to ( P p ) an employee laced for adoption with to y ee durin to include an election of continuation of coverage on behalf of any other qualified
i� beneficiary who would lose coverage under the Plan by reason of the termination. If
Ii, I the COBRA continuation period: These children will .receive all rights of a qualified
beneficiary throughout the COBRA continuation period. any other qualifying event occurs, the election of continuation of coverage by the
N spouse shall be deemed to include an election of continuation coverage on behalf of
A qualifying event means the, occurrence of any of the following events, which would any other qualified beneficiary who would lose coverage under the Plan by reason of
result in the loss of coverage to: the qualifying event.
(1) Employee: The cost of coverage to the qualified beneficiary shall be 102% of the cost of providing
(a) Termination of employment for any reason other than gross misconduct. coverage for such period to a similarly situated participant under the Plan to whom a
(b) Reduction of work hours. qualifying event has not occurred. In the event the qualifying event entitling the
qualified beneficiary to continuation of coverage is the covered beneficiary's disability
ry (2) Spouse: as defined by the Social Security Act, the cost of coverage to the qualified beneficiary
(a) Termination. of employee's employment. for any month after the 18th month of continuation coverage following the date of
(b) .Reduction of employee's work hours. termination shall be 150% of the cost of providing coverage for such period to a
(c) Death of employee. similarly situated participant under the Plan to whom the qualifying event has not
occurred. The cost of coverage shall be paid directly to the employer in monthly
(d) Divorce or legal separation from employee. installments.
(e) Employee becomes enrolled in Medicare.
(f) A covered dependent child ceases to be a dependent under the Plan. In the event of a covered employee's termination, the period of continuation of
(3) Dependent:
coverage is:
(a) Termination of employee's employment. (1) Up to eighteen (18) months from the date of said termination for such
(b) Reduction of employee's work hours. employee and the employee's qualified beneficiaries.
(c) Death of employee. (2) Up to thirty-six (36) months from the date of employee's death, divorce, or
legal separation for such employee's covered surviving spouse, divorced
(d) Divorce or legal separation from employee. souse legally separated spouse and such employee's to ees cove ed dependents.
P g Y P P P Y r
(e) Employee becomes enrolled in Medicare.
fl, (f) Dependent child ceases to be an eligible dependent as defined by the (3) Up to thirty -six (36) months from the date a covered dependent child ceases
ud, Plan to be covered as an eligible dependent under the Plan.
i ( Continuation of coverage is conditioned upon satisfaction of the following notice (4) Up to thirty -six (36) months from the date the covered employee becomes
entitled to Medicare benefits for the employee's covered spouse and
requirements. The notice requirement relating to election coverage by qualified dependents.
beneficiaries is as follows:
(5) Up to twenty-nine (29) months from the date of such termination for such
(1) In the event of an employee's death, termination of employment or Medicare employee and such employee's qualified beneficiaries, if it is determined,
eligibility, the employer shall notify the Trust within thirty (30) days of such under Title II or XVI of the Social Security Act, the covered employee was
event. Upon receipt of notice, the Trust shall, within fourteen (14) days, disabled on the date of termination. The employee must notify the Trust of
notify the qualified beneficiary of his /her right to elect continuation coverage said determination within sixty (60) days of said determination and within
under the Plan. eighteen (18) months of the date of termination. In the event another
it (2) In the event of divorce, legal separation or a dependent child ceasing to ' u event occurs during the eighteen 18 months following g P P t; qualifying g gh ( ) g the date of
qualify as a dependent under the Plan, the employee or the qualified the employee's termination, the period of continuation of coverage is up to
beneficiary is required to notify the Trust within —sixty (60) days of such thirty -six (36) months from the date of termination for such employee and his
qualifying event. Upon receipt of notice, the Trust shall, within fourteen (14) qualified beneficiaries.
days, notify the qualified beneficiary of his /her right to elect continuation of
coverage under the Plan. A qualified beneficiary's continuation of coverage shall cease on the earliest of the
•• uNananawaesdroaNmesee .aworswsd(7 /esl Page 28 unknoom k..weulom.sdueaemBwmWro(7 /ss) Page29
Florialdbhnlclpal Insurance Trust Medical Master Plan of Benefits • Florida Municipal Insurance Trust Medi�ter Plan of Benefits
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following: (1) Drugs related to a course of treatment excluded, or a condition limited under
(1) The maximum coverage period date allowed for the qualifying event;
the Plan.
(2) The date on which the employer ceases to provide any group health plan to (2) Injectable products and syringes (other than insulin and insulin syringes).
all employees; (3) Prescription Vitamins.
(4) Nicorette Gum, Nicotine patches such as Habitrol, ProStep, Nicoderm.
(3) As provided in Section XI, if the qualified beneficiary fails to pay
contributions within thirty (30) days after they become due; (5) Viagra and other similar virility enhancement drugs.
(6) Rogaine and other similar medications for baldness.
(4) The date the qualified beneficiary becomes covered under another group
health plan (as an employee -or. otherwise) with similar coverage, which does (7) Anorexics (appetite depressants such as "diet pills ").
not contain any exclusions or limitations for pre - existing conditions; (8) Diabetic Test Strips and glucometors.
(5) The date the qualified beneficiary becomes entitled to Medicare benefits; (9) Over the Counter medications and supplies.
(6) If the coverage period is twenty -nine (29) months and the employee ceases to (10) Over the Counter Vitamins.
be totally disabled, on the first day of the month within the coverage period (11) Drug prescriptions of thirty (30) or more days' duration.
that begins more than eighteen (18) months after the date of termination and A Prescription Mail Program is available to meet the maintenance drug
is more than thirty (30) days after the date on which the employee ceased to P g prescription
needs
be totally disabled under Title II or XVI of the Social' Security Act. However, s a participant. Only maintenance drug prescriptions p over thirty ( days
and less
in no event shall the coverage period extend beyond twenty -nine (29) months s than ninety -one (9 1) days' duration are eligible for this program. No coverage
from the date of termination. Notwithstanding the above, in no event shall
is provided for the exclusions specified in Section VIII, and Items (1) through (10)
said coverage extend beyond the twenty-nine 29 month coverage listed above.
g Y. ty I } period.
g P
A certificate of creditable coverage will be issued at the end of the continuation of
coverage - period. The certificate will be sent by FirstClass Mail to the participant's last SECTION XVII — GENERAL PROVISIONS
known address. In addition, the Trust shall issue a certificate of credible coverage to
a participant upon request, for up to 24 months following the end of the participant's The Trust will issue to the employer for delivery to each participating employee
coverage under this Plan. covered hereunder, a Schedule of Benefits, a copy of this Plan and appropriate
identification cards, which the employee or eligible covered dependents can present to
If COBRA is elected and the eighteen (18) or thirty-six (36) months maximum time a hospital, physician or other service provider in cl aimin g benefits due under this
frame is exhausted, the qualified beneficiary may be eligible for coverage under an Plan. It shall be the employer's responsibility to disseminate to the eligible employee
individual plan (through an insurer of their choice) on a guaranteed issue basis the Schedule of Benefits, a copy of this Plan and the appropriate identification cards.
without any pre - existing condition limitations. The employee's benefits are non - assignable prior to a claim. If any amendment to this
Plan shall materially affect any benefits, the amendment, a new Schedule of Benefits
In the event the Plan offers a conversion privilege, the qualified beneficiary shall be and an updated copy of this Plan shall be delivered to the participating employer to be
entitled to said conversion privilege provided the qualified beneficiary applies for such distributed to employees. The Trustees shall provide benefits that are designed to
conversion plan during the last 180 days of the period of continuation coverage. meet the needs of the participants and that are based on actuarial soundness. The
Plan may be modified or discontinued by the Trustees at any time. Notices of
Coordination of Benefits with other plans for COBRA recipients will follow current modification or discontinuance shall be mailed to the employer's last known address
National Association of Insurance Commissioners (NAIL) recommendations. at least forty-five (45) days prior to the effective date of such modification or
discontinuance.
SECTION XVI — PRESCRIPTION DRUGS All statements made by employers or the employees of such employers shall be
deemed representations and not warranties and no statement made for the purpose of
Coverage is provided for prescription medications prescribed by a physician which are effecting coverage shall void such coverage or reduce benefits unless contained in a
intended for use outside a hospital, skilled nursing facility or treatment facility. written instrument signed b y
the employer er or employee of such employer, a co of
Benefits will be paid at the coverage level shown on the Schedule of Benefits. which has been furnished to such employer or employee ee be. PY
P Y as the case may
Presenting your prescription identification card each time you request a prescribed
medication will ensure that the provider knows that you are part of the plan. A No reduction in benefits shall be made by reason of change in the occupation of any
generic prescription drug will be provided unless the prescribing physician specifies a mployee while in the employ of the employer or by reason of the employee's doing
e
brand name drug. any act or thing pertaining to any other occupation, except as otherwise provided in
Section VI.
in addition to the applicable exclusions specified in Section VIII, no coverage is
provided for: No representative has autho rity to change this Plan or waive any of its provisions. No
'-Unloss.11MAW amdInobsoh.ewaore.-s4(r /se) Page 30 —U nlow ahad oo Stated m ff. schsam.ofBon.nts(r /es) Page 31
Flo ri Icipal Insurance Trust Medical Master Plan of Benefits •
Florida Municipal Insurance Trust Muster Plan of Benefits
change in this Plan shall be valid unless approved by the Board of Trustees. arises. The burden is on the applicant or participant to make complete and accurate
Written proof of claim for services shall be furnished to the Trust within 365 days
representations to the Trust concerning questions of eligibility, coverage and services
or benefits under this Plan .
after the date of such services.
Benefits provided in this Plan will be payable to the hospital, physician or other
service provider rendering service under this Plan or to the participant upon receipt, SECTION XVIII — PAYMENT OF BENEFITS, ASSIGNMENT
by the Trust, of paid bills in acceptable form. Benefits provided under this Plan for a specified injury or sickness may be paid to the
No action at law or in equity shall be brought" to recover under this Plan prior to the
participant or to the service provider who has provided or paid for services or supplies
expiration of sixty (60) days written notice to the Trust. No such action shall be for which such benefits are payable. Such benefits may be assigned by the
brought after the expiration of the specified statute of limitations on such action. participant to such provider and will be paid according to the participant's
designation on the claim form, but only to the extent such provider's interest shall
Such notice to the Trust shall be sufficient if given to: appear; otherwise this Plan and such benefits are non - assignable. If benefits are paid
The Florida Municipal Insurance Trust prior to the receipt and acceptance by the Trust of any assignment of such benefits,
Attention: Health Department the assignment shall be null and void and unenforceable against the Trust.
135 E. Colonial Drive
Orlando; Florida 32801 In the event an employee or dependent dies, or is physically, mentally or otherwise
under this Plan for himself herself or eligible incapable of making payment due to a service provider, Plan benefits may be aid
1 ' for coverage u
An employee a / Y P
PP Ymg
dependents and the participant and /or each dependent of the participant agrees that, directly to the service provider or to any person or institution appearing to assume
as a condition of payment of,benefits,.services, and supplies, any hospital, physician responsibility for the expense, and such payment shall discharge the Trust's
or other service provider that has made or may hereafter make a diagnosis, render obligation for such expense.
service, attendaripe pr trc#tment of or to a „Qarticipant, may furnish and is authorized
” to furnish to the Trust at any time upon its request, a report containing all
information and records or copies of records pertaining to diagnosis, attendance,
service or treatment. The applicant or participant and /or each dependent of the SECTION XIX — GRIEVANCE PROCEDURE
applicant or participant agrees as a condition of payment of benefits or services, to There are situations when participants have questions about their coverage or are
execute such medical authorization as may be required by the Trust. dissatisfied with Plan services. Such inquiries and complaints will be handled in a
The Trust shall not be responsible for the payment of any expense for services or timely manner.
supplies not covered by this Plan or any amounts in excess of the maximum benefits
allowed by this Plan. In the event that a claim is denied and the participant disagrees with the denial, a re-
determination may be requested in writing detailing the reasons for the disagreement.
Eligible new participants may be added to the Plan in accordance with the terms and This request must be received within sixty (60) days of the initial claim denial. The
conditions of the Plan. Plan will respond with a written decision, within sixty (60) days from receipt of the
request.
No otherwise eligible employee or dependent of a participating employer, shall be
refused coverage or be charged an unfairly discriminatory rate for participation solely
because such employee or dependent is mentally or physically handicapped; provided, SECTION XX — SUBROGATION
4I however, nothing in this Plan shall be construed to require the Trust to provide
�I coverage against a handicap which the applicant sustained on or before the In the event of any payment for benefits, services or supplies provided to a participant
applicant's effective date of coverage. under the Plan, the Trust, to the extent of such payment, shall be subrogated to all
€ rights of recovery such participant has against any person or organization, and the
h C In the event coverage under this Plan is conditioned upon a certain event or Participant, as a condition precedent to the payment for any benefits, services or
su p p lies lies otherwise able under this Plan, shall execute and deliver such a
'k condition, or conditioned upon the continuation of a certain event or condition, the _._ PP p ayable
burden is on the participant to establish the existence of such event or condition or instruments and papers as may be required and do whatever else is necessary to
the continuation of such event or condition. secure such rights to the Trust and shall otherwise assist and cooperate with the
Trust as may be necessary in its efforts to recover such payment.
To the extent of any conflict, the express words and language in this Plan will prevail
over any oral or written communications to or by the Trust concerning the terms and
conditions expressed in this Plan and such communications are hereby deemed to be
modified to reflect the terms and conditions in this Plan in the event such conflict ry
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FlorldAl Insurance Trust Medical Master Plan of Benefits • . Notes
SECTION XXI — NOTICE
Notice to an employer given under the Plan shall be sufficient if given to the employer
when addressed to its office stated in the Participation Agreement; except as
otherwise herein expressly provided, if given to:
The Florida Municipal Insurance Trust
Attention: Health Department
135 E. Colonial Drive
Orlando, Florida 32801
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