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Home My WebLink AboutDocumentation_Regular_Tab 14G_04/08/1999 ~~V F Tf r ~~.. M f~ aM E M O R A N D U M o= .~ ' - 4" H 1 CO To: Village Council From: Thomas G. Bradford, Village Manager ~~~`~ / Date: April 2, 1999 Subject: Tequesta Health Insurance Benefit Plan; Recommendation to Change Service Provider; Agenda Item Tequesta currently provides health insurance benefits to its employees through United Health Care. The Village pays 1000 of single coverage and 75 0 of the cost of the family plan. United Health Care has indicated to the Village that the cost of the plan will increase by 13% effective May 1, 1999. Accordingly, efforts were undertaken to secure alternative proposals for comparison purposes. Due to potentially serious existing conditions of some employees, Tequesta received only one proposal to the United Health Care plan. Triis proposal was from the Florida Municipal Insurance Trust (FMIT), the same firm that Tequesta secured health benefits from prior to switching to United Health Care. The FMIT plan, while requiring a $10.00 co-pay compared to the United $5.00 co-pay, provides for a larger services network, will enable the Village and its employees to receive a dental insurance discount from FMIT (the same firm we currently receive dental insurance from), has greater benefits when the employee goes outside of the network, and will provide savinga to Tequesta in .excess of $73,000 per annum and to Tequesta employees in excess of $12,000 per annum versus that to be paid to United effective May 1, 1999. In comparison to what is currently paid to United, Tequesta is estimated to save in excess of $37,000 annually while Tequesta employees are estimated to save in excess of $6,300 annually versus what they currently pay for their portion of the health insurance benefit. For your information, the Town of Juno Beach, Wellington and Royal Palm Beach are local municipalities currently receiving health benefits from FMIT. If approved by the Village Council, an orientation/presentation for all employees relative to the new plan will be conducted prior to May 1, 1999. The Fraternal Order of Police have been notified of the potential change pursuant to the Collective Bargaining Agreement with Tequesta, and the Communications Workers of America's representative has been notified of the proposed change as well. It is anticipated that the CWA will approve the proposal since the same will mean an out-of-pocket savings to its membership. Based upon the foregoing, it is recommended that the Village Council approve using FMIT effective May 1, 1999 as the service provider for Tequesta's health insurance benefit plan. TGB\ecr \Village Council\4-2-99 Memo This document contains time-sensitive information. Please read immediately and respond as specified. To Thomas G. Bradford, Village Manager From Kim Bodiniao, Personnel Specialist Date/Time March 3 I , 1999 Subject Employee Group Health Insurance Proposals fr Attached, please find two (2) proposals for group health insurance received from Acordia Southeast and Florida League of Cities, Administrator, Florida Municipal Insurance Trust, for your review for the purpose of recommending a health insurance carrier prior to renewal on May I, 1999. Please note while reviewing this information that several companies declined to quote group heakh insurance for the Village of Tequesta this year due to current medical conditions and underwriting guidelines. The insurance proposals received are from our current carrier, United Healthcare of Florida, with an approxirrate 13% increase in premiums, and Florida Municipal Insurance Trust. Some basic information to consider on each policy is as follows: UNITEt~ HEALTHCARE POS Plan $5.00 Co-payment Network area limited to Dade, Broward & Palm Beach Counties Covers 70% out-of-network after $500.00 deductible FMIT POS Plan $ 10.00 Co-payment Larger network area, including Martin & St. Lucie Counties Covers 80% out-of-network after $300.00 deductible Substantial savings to both the VOT and employees (see attached spreadsheets in this regard). Please let me know as soon as possible if you need clarification on the attached materials. /krb 25o Tequesta Drive Attachments Suite 300 lotus\work\wordpro\insurancelhealthrenewal Tequesta. Fkc; ;da 33469 561-575-6209 561-575-b203 Fax Lrl UNITED FIEALTF~CARE PdS 210 PLAN w $5.00 Co-Pay (Expires 4/$0199) Plan ~~~ Nq~gf ~a~tiC~ar~~s yQ"f AnOu~l ,Cast Em~_Annwal (host ANNUAL C~06T employee Only 28 $66,850.56 $0.00 $60,850.56 Family (spouse andlor children) 38 $195,39$.2$ $34,890.84 $230,289.12 TOTR,LS: 66 $262,248.84 $34,890.84 $297,139.68 UNITED HEALTHCARE pCJS 210 PLAN - $5.00 Co-Pay (Effective 511199 Employee OhIY 28 $75,539.52 $0.00 $75,539.52 Family (spouse and/or children) 38 $220,79'8.76 $39,425.76 $260,225.52 "f01'ALS: 66 $296,339.2$ $39,425.76 $335,765.04 FLORIDA MUNICIPAL INSURANCE TRUST PQS GOLD PLAN - $10,00 Co-Pay (Effective 5/1/99) Employee OnIY 28 $5$,920.96 $O.bO $58,920.90 ~rriploy~ee/Spouse 9 $35,132.40 $5,397.84 $40,530.24 FmployeelChild(ren) 12 $41,351,04 $5,365.44 $46,716.48 Fmplayee/Spouse/Child(ren) 17 $89,166.36 $17,799.00 $106,965.36 TOTALS: 66 $224,570.76 $28,582.28 $253,133.04 Annual savings - EMIT vs, UHC: $7'1,768.52 $10,863.48 $8Z 63~".00 Annual Savings .Dental Iris bi5cdunt w! FMIT Heaith Ins, $1,5$4.00 $1,'188,00 , TOTAL ANNUAL SAVINGS -Health and Dental w/FMIT $73,35.52 $12,051.48 HEALTH INSURANCE PROPOSAL DETAIL SHEET UNITED HEALTHCARE POS PLAN (Expires 4/30199) Plan Monthly Plan Annual Cost VOT Annual Emp. Annual Pay-off Deduction Type Cost Per Employee Contribution Percent Contribution Percent Bi-Weekly Employee Only $198.96 $2,387.52 $2,387.52 100% $0.00 0°~ $0.00 Family $505.02 $6,060.24 $5,142.06 75% $918.18 25% $35.31 UNITED HEALTHCARE POS PLAN (Effective 511/99) Employee Only $224.82 $2,697.84 $2,697.84 100% $0.00 0% $0.00 Family $570.67 $6,848.04 $5,810.52 75% $1,037.52 25% $39.90 FLORIDA MUNICIPAL INSURANCE TRUST POS GOLD (Effective 5/1/98) Employee $175.36 Spouse $199.92 Children $149.06 Medicare Supplement $161.00 Scenarios: Employee Only $175.36 $2,104.32 $2,104.32 100% $0.00 0% $0.00 Employee/Spouse $375.28 $4,503.36 $3,903.60 75% $599.76 25% $23.07 * Employee/Children $324.42 $3,893.04 $3,445.92 75% $447.12 25% $17.20 Employee/Spouse/Children $524.34 $6,292.08 $5,245.08 75% $1,047.00 25% $40.27 *FMIT will provide $3 00 per month discount to VOT for Dental Plan currently in place if FMIT Health is chosen, resultin g in a $1.39 bi-weekly savings . to the employee choosing this health optio n and having family dental coverage. In such cases, deduct $1.38 from bi-weekly figures shown. VILLAGE OF TEQYJESTA COMPANY UNITED HE ALTHCARE 210 Plan I'AIVS POS 210T Plan 400T Plan 600T Plan efts In Netwoiic Out of Network PO In Network S Out of Network P In Network OS Out of Network POS In Network Out of Netwo>ic HYSICIAN SERVICES ce VLits CO-PAY -PRIMARY fflce Visits CO-PAY -SPECIALIST 100% after $S co-pay $S co-pay 70% of allowance after annual deductible 100% after $3 co-PaY $S co-pay 70% of allowance attar atmual deductible 100?io after $10 co- a P Y $10 co-pay 70% of allowance after annual deductible 100% after $15 co-pay $15 co-pay 70% of allowance after annual deductible 70% f ll NPATIENT HOSPITAL SERVICES 100% o a owance after annual deductible 100% 70% of allowance after ~~ deductible 100% after $250 co-pay 70% of allowance after annual dedu tibl 100% after $500 co-pay o 70 /° of allowance after annual 70% f c e deductible MERGENCY ROOM SERVICES 100% after $SO co-pay o allowance after annual deductible 100°k after $SO co- a P Y 70% of allowance ~e1 ~~ deductible 100% after $SO co-pay 70% of allowance after annual deductible o 100 h after $50 co-pay 0 70 /o of allowance after annual T same as any same a deductible ERNITY SERVICES RESCRIPTION DRUG BENEFITS illness 100% after s any tliness same u aay illness same as any illness same as any illness same as any illnoea same as any illness same as any illness eneric rand -Form glary rand -Non-Formulary ASH DEDUCTIBLE $S co-pay $3 co-pay N/A N/A 100% after $S co-PaY $10 co-pay $15 co- a P Y N/A ° 100% after $8 co-PaY $13 co-pay $18 co-pay N/A 100% after $8 co-PaY $13 co-pay $18 co-pay N/A dividual / Fam11y) UT-OF-POCKET none $500 / $1,000 none $500 / $1,000 Hotta $500 / $1,000 cone $500 / $1,000 ~~~ / FamdlY) $1,500 / $3,000 $3,300 / $7,000 $1,500 / $3,000' $3,300 / $7,000 $1,500 / $3,000 $3,300 / $7,000 $1,500 / $3,000 $3 300 i $7 000 ETIME MAXIMUM unlimited $2 000 000 n , ; ONTHLY PREMIUM RATES ployee (2~ ployee and Faua>ily (40) ONTHLY TOTAL CURRENT $198.96 $505.02 $25 373 76 , , RENE~I~7AI, $224.82 $570.67 $28 672 12 u limited $2,000,000 ALTERNATE $214.88 $545.42 unlimited $2,000,000 PROPOSED $202.34 $513.58 unlimited $2,000;000 PROPOSED $195.25 $495.60 NNUAL TOTAL , . , . $304,485.12 $344,065.44 $27,403.68 $328,844:16 $25,804.04 $309;648.48 $24,900.50 $298,806.00 Tliis-summary is not intended to be a complete explanation of benefits of the proposed insurance policies. Actual premiums and benefits will be determined by the final enrollment and are subject to underwriting approval. 5 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. THEREFORE BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE VILLAGE TEQUESTA, PALM BEACH COUNTY, FLORIDA AS FOLLOWS: 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. fE FOREGOING RESOLUTION WAS OFFERED by Councilmember who moved its adoption. The motion was seconded Councilmember and upon being put to vote, the vote was as follows: FOR ADOPTION AGAINST ADOPTION 'he Mayor thereupon declared the Resolution duly passed and adopted :his 8t'' day of April, A.D., 1999. MAYOR OF TEQUESTA ATTEST: oann Manganiello illage Clerk P80\Resolution\Health Insurance EX~llb~t itA~~ Health Rate Options POS Gold EmployeeMedical 9pvuse Medic Child(ren) Medical MEDICARE SUPPLEMENT 3175.36 $199.92 $149.06 $161.00 ~~ ~ t -,-.'"" ' J Florida Municipal Insurance Trust Major Plan Benefi# In Ne#work C}u# of IVe#work 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 ~'f4S-##c~~ ~ex"V1CGS • 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 ~~1~/S~Cldn SQt'VlC~''S • 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 • 08/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 Heal#h Care Services • Prescription Drugs (RX Net) • Mental & Nervous Disorder • Inpatient Services (30 days per calendar year maximum) • Outpatient Services (20 visits per year limit) $10,000 calendar year maximum $25,000 lifetime maximum • Alcohol and Drug Dependency • Individual Visit • Hospice Care (6 month maximum care) $6,000 lifetime maximum • Home Health Care (60 visits per year maximum) • Physical Therapy (40 visits per year maximum) $2,000 calendar year maximum • Skilled Nursing Facility (75 days per year maximum) $10,000 lifetime maximum • Chiropractic Services (26 visits per calendar year) • Routine X-Rays, Lab Tests, Diagnostic Services In Network Out of Network $5.00 Generic Wholesale Price, less 10%, $10.00 Brand less In Network Co-Pay $100.00 Co-Pay, $500.00 Deductible, then then 100% 80% of covered charges $10.00 Co-Pay, 80% of covered charges then 100% $50.00 per visit maximum $10.00 Co-Pay 80% of covered charges 100% 80% of covered charges i 00% 80% of covered charges 100% 80% of covered charges 100% 80% of covered charges $10.00 per visit 80% of covered charges $40.00 per visit maximum 100% 80% of covered charges O All surgical procedures must be pre-certffled. ~ All non-emergency hospital stays must be pre-certified. ~ All Out of Network Benefits are covered at 809~e 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. fr All In Network Co-Pays apply toward the annual maximum out of pocket expenses. 3 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, limi#ations, and exclusions of the plan. Complete terms of the plan are contained in the Master Plan of Benefifs.) Flov~iAl~c Mzsnicip~ct INSURANCE TRUST CERTIFICATE OF COVERAGE MEDICAL PLAN OF BENEFITS FLORIDA LEAGUE OF CITIES Florida Municipal Insurance Trust Certifiicate of Coverage This Certificate of Coverage and Medical Master Play 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 plea. 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 fulSlling any duties or obligations of as 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 is 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 is force by the timely payment of the required plan charges when due, subject to termination of the plan as provided. All coverage under the plea 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 Section Hea I. DEFII~IITIONS-----------------------------------y----------------------------- 1 II. DEDUCTIBLES --------------------------------------------------------------- 6 III. LIFETIME MAXIMUM AND RESTORATION OF BENEFITS---____-- 6 IV. MAXIMUM EXPENSE TO PARTICIPANTS------------------------------ ? V. ELIGIBILITY AND ENROLLMENT_________________________________________ 7 VI. COVERED EXPENSES -----------------------------------------------------12 VII. HQSPITAL BILL SELF-AUDIT --------------------------------------------19 VIII. EXCLUSIONS AND LIMITATIONS _______________________________________20 IX. COORDINATION OF BENEFITS -----------------------------------------23 X. PRE-EXISTING CONDITIONS LIMITATION3 _________________________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 ____________________________28 XVI. PRESCRIPTION DRUGS --------------------------------------------------- 30 XVII. GENERAL PROVISIONS ---------------------------------------------------31 XVIII. PAYMENT OF BENEFITS, ASSIGNMENT ______________________________33 XIX. GRIEVANCE PROCEDURES ---------------------------------------------- 33 XX. SUBROGATION--------------------------------------------------------------33 XXI. NUTICE ----------------------------------------------------------------------- ~ Florida Municipal Insurance Trust Medical Master Plan of Benefits SECTION I -DEFINITIONS Accideat means anon-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. Beaef3ts 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 astate-licensed facility or institution equipped to provide and provides prenatal care, delivery, immediate postpartum care of a child at the facility, ltas 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-paV 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 ?ndicating their participation in the coverage pro~~ided 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 s•Unkssetll In ths~Ch4~ule ot&~eMs (7/98) i+age ~ 3 ~. .. _. ~_ ~. „r..- -- - - - in the United States and its territories. A child is a dependent if the child meets the following conditions: (1) the child is a natural child, stepchild, legally adopted child, or a child who has been placed under the legal court-ordered guardianship of the participant, and (2) the child is in the custody of and financially dependent upon the participant. (This is waived if the participant is required to provide coverage to the child due to court order or divorce decree.) A newborn child of a participant having dependent coverage is entitled to the same benefits as the participant; provided, however, a dependent child shall not be entitled to maternity benefits under this Plan. A newborn child of a dependent child covered under the Plan shall terminate 18 months after the birth of the newborn child. A dependent child shall cease to be a participant at the end of the calendar year in which such child reaches age 19. However, if such child is in full-time attendance at an accredited school, college, or university and is dependent upon the participant for support, coverage will continue until the end of the calendar year` irr which the child reaches age 25, or' upon the marriage of such child, whichever event shall first occur. Full-time attendance means that the student is enrolled..for.,thenumber.of.houra.which.is-.considered.to be afullaime:,attendaace by the institution the student is attending. Satisfactory proof of such attendance shall be furnished to the Trust upon request. A dependent child, regardless of age, shall continue to be covered under this Plan while the child is and continues to be: (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap; and (2) chiefly dependent upon the employee for support and maintenance;' provided such condition occurred while such dependent was covered under this Plan. Satisfactory proof of such continuing incapacity and dependency must be furnished to the Trust. (3) The burden is on the participant to establish such dependent meets or continues to meet the criteria specified in (1) and (2). Parable Medical >~pment means medical equipment designated for repeated use and which is medically necessary to improve the functioning of a malformed body member, or to prevent further deterioration of the patient's medical condition. Emplavee means an officer or employee of the employer or any class or classes of such employees, regularly working thirty (30)** or more hours a week, who is eligible for coverage hereunder, who has been so designated by the employer and who holds a valid Social .Security Number. This definition shall include elected officials of the employer and employees who have retired and are receiving retirement benefits pursuant to a retirement plan lawfully established and maintained by the employer. Employer means each and every county, municipality, school board, special taxing district or local governmental unit established within, and pursuant to the laws of, the State of Florida and which becomes a party to this Trust by executing a ••uN.n.aN,w,..uewMm.xh.ew.rtew.ne.p/wl Paga2 rwnaa munxapa~ ~eeurance true[ _ _ Medical Master Plan of Benefits Participation Agreement, and who has agreed to be bound by all the terms and provisions of the Trust Agreement, the Participation Agreement and the rules and regulations adopted by the Trustees in the administration of the Trust. HIV infection os a snedfic siolcaess os medical condition derived from such infection means the human immunodeficiency virus identified as the causative agent of acquired immune deficiency syndrome, Acquired Immune Deficiency Syndrome, an acquired immune deficiency syndrome-related complex, or a specific sickness or medical condition derived from such infection. Home Health AEeacv means any state licensed public agency or private organization that is equipped to provide and provides home health services. Home Health 8orvioes means any or all of the following health and medical services and medical supplies when furnished to an individual by a home health agency in a place of residence used as a participant's home: (1) part-time or intermittent nursing care provided by a Registered Graduate Nurse or a Licensed Practical Nurse; (2) physical, occupational, or speech therapy; (3) medical social services, home health aid services, and nutritional guidance; (4) medical supplies, other than drugs or biologicals prescribed by a physician, and the use of medical appliances. Hosyiee Care means caze given to a terminally ill participant by or under arrangements with a hospice care agency, and must meet the standazda outlined by the National Hospice Association. 8osyice Care A¢eacv means a state licensed organization and which: (1) has twenty-four (24) hour hospice care available; and (2) provides skilled nursing services, medical social services, psychological and dietary counseling; sad (3) provides physician services, physical therapy, part-time home health aide services and inpatient care; sad (4) keeps medical records; and (5) has afull-time administrator. gQlD~~~ means an institution which is licensed and operated in accordance with the laws of the jurisdiction in which it is located pertaining to institutions identified as hospitals, and which is primarily engaged in furnishing for compensation, diagnostic and therapeutic facilities for surgical and medical diagnosis, which provides treatment and care of injured and sick persons by or under the supervision of a staff of physicians who aze duly licensed to practice medicine, end which continuously provides tarenty-four (24) hour a day nursing service by Registered Graduate Nuraea, and which is not, other than incidentally, a sanitarium, nursing home, place for rest, place for the aged, place for drug addicts or place for alcoholics. "Hospital" also means: (1) an institution which is an "ambulatory surgical center", as defined and licensed under Florida Statutes, or (2) a "Psychiatric Hospital" which is an institution legally constituted and ••uw.r.a«.r.a.aa~.a.a.+~.da.rnsl7/a~ Paga3 Florida Municipal Insurance Trust Medical Master Plan of Benefits licensed as a psychiatric hospital and properly accredited to provide psychiatric, diagnostic and therapeutic services for the treatment. of patients who have mental illnesses. litosnital Service means and includes receiving a participant into a hospital for services set forth in this Plan and outlined on the hospital bill and subject to the rules and regulations of the hospital, for and during such time only as the participant is necessarily treated on an inpatient or outpatient basis in the hospital, under the treatment and care of a physician for any conditions covered hereunder. ti means a patient who has been admitted upon order of a physician as a bed patient for treatment in a hospital for at least six (6) continuous hours. Lifetime Maaimnm means the maximum liability of the Trust subject to the benefits provided in this Plan, with respect to each participant covered under this Plan, during the entire period such participant is covered hereunder. Massage Therapist means a person properly licensed to administer massages, pursuant to Chapter 480 of the Florida Statutes, or other states' applicable law. Medically Necessary means treatment, care or services that are consistrnt with the diagnosis, complies with acceptable medical standards, is not primarily for the participant's convenience and is the most appropriate level of service which can be safely provided. When applied to hospital inpatient care, it means that caze cannot be safely provided on an outpatient basis. Care that has not received federal approval will not be considered medically necessary. ~d€f means any person, other than a licensed physician or Certified Nurse Midwife, who is state licensed to practice midwifery. Midwifery means the practice of supervising the conduct of a normal labor and childbirth, with the informed consent of the parent; the practice of advising the parents as to the progress of childbirth; and the practice of rendering prenatal and postnatal care. New l+lmplovee means an employee who has never been previously employed by the employer prior to the effective date of this Plan and who is employed by the employer on or after the effective date of this Plan, or an employee who was employed by the employer prior to the effective date of this Plan and was ineligible to pazticipate in the employer's prior plan because the employee had not completed the period of continuous employment with the employer as set forth in such plan, if any, to qualify to participate in such plan. Occupational Therap ^~ means a person who is duly registered or licensed by the state in which such person is engaged in the practice of occupational therapy and who is a member of the American Occupational Therapy Association. Outpatient means a patient who has not been admitted to a hospital as an inpatient and who has not beer: chazged for room and boazd. Participant means and includes the employee and any of his or her legal dependents covered under this Plan. Participant also means and includes those employees and their dependents that qualify for continuation of coverage under COBRA. ..uM.o.uw.b.maa~na.sah.ae.eea.Mwp~sel Page4 Florida Municipal Insurance Trust Medical Master Plan of Benefits Physical Therapist means a person who is duly registered or licensed by the state in which such person is rngaged in the practice of physical therapy and who is a member of the American Physical Therapist's Association. pj3nieal Therapy means the diagnosis, treatment, prevention, or rehabilitation of any injury, disease, or other health condition, including the use of appazatus and equipment directly related thereto, by the use of physical, chemical, and other properties of av; electricity; exercise; massage; radiant rnergy, including ultraviolet, visible or infrared rays; ultrasound; or water; or by the use of acupuncture or tests of neuromuscular functions; provided ouch diagnosis, treatment, prevention, or rehabilitation is performed pursuant to minimum criteria and standards of practice established by a statutorily created board that primarily consists of physical therapists and/or physicians and pursuant to a written plan of treatment prescribed and approved by a physician. Physician means a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) legally qualified to practice medicine and perform surgery at the time and place the service is rendered. For services covered under this Plan, doctors of dental surgery (D.D.S.), doctors of podiatry (D.P.M.), and doctors of chiropractic (D.C.), when acting within the scope of their licenses, are deemed to be physicians. P n means this Master Plan of Benefits, including any Schedule of Benefits attached hereto. ~s-existiag CondigQS means any condition, physical or mental, for which medical advice, diagnosis, care or. treatment was recommended or received within the twelve (12) month period ending on the enrollment date. Preveatative Care means services and supplies ordered and/or provided by or under the direction of a physician for which there is no medical diagnosis or does not seek to diagnose, Lreat, or cure a sickness or injury. Reasoaa6le Fee means the benefit allowances as determined by the Trust for all eligible expenses incurred by a participant. The basis will be the relative value studies and schedules utilized and evaluated by the Trust. The benefit allowances utilized by the Trust are determined by studies of charges for similar benefits within a common geographical area. These studies aze used to develop benefit value schedules that are updated on a routine basis. Registered (iradnate Nurse or Liceased Practical N nA moans a person duly hcensed by the state in which such person is engaged in the practice of nursing. Rehabilitative Services means health care services for the purpose of which is to restore functional defects. Rout3ae Care means services and supplies ordered and/or provided by or under the direction of a physician for the purpose of the diagnosis, treatment, or cure of a sickness or injury. Secoad SurQieal Oy ioa means the second opinion contained in a written statement on the necessity for the performance of a covered surgical operation given by a board-certified specialist who, by the nature of the physician's specialty, qualifies the physician to consider the surgical opinion being proposed and who is not associated with the physician initially recommending the surgical operation. «ow.r.a.nw,..w,eNS,.a<h.+W..es.n~ns pMI Page 5 Florida NCunlclpal lnsurasce Trust Medical Master Plan of Benefits Service Provider mcans a state licensed person or organization providing services deemed to be covered expenses under this Plan. Sickness means a bodily disorder, illness, or infirmity, which has been or is diagnosed by a physician. Skilled Nnrsia¢ Facility means a state licensed institution which provides 24 hour nursing..caze for a patient whose condition does not warratlt hq~pita)i~stio{l artd has been approved for payment by the Trust. The facility can .operate independently or as part of a hospital. Total Disability means a medically determinable physical or mental impairment which renders a participant so incapacitated as to be unable to engage in any gainful occupation, within the range of his/her normal ability, and taking into consideration education, training and work experience. Trust means the Florida Municipal Insurance Trust, its Trustees and individuals or organizations designated by the Trustees to act on their behalf. BECTION II -DEDUCTIBLES Iadividnal Dednet3ble - In the event the participant shall incur expenses for covered medical services on or after their effective date of coverage, benefits will be provided as follows for such expenses (except for any amount in excess of the reasonable fee). Such expenses shall be subject to a deductible applicable under this Plan, and as set forth in the Schedule of Benefits, for each covered participant during each calendar year. >~iy Dednetible -All covered participants within a family shall be subject to the maximum accumulative deductible as set forth in the Schedule of Benefits during each calendar year. Dsslnctible credit from employ prior covara^e - In the event a participant has incurred and paid covered expenses during a calendar year under any other group health insurance plan issued to the employer which was in effeM immediately prior to the participant's coverage under this Plan, then the amount of such covered and paid expenses shall be credited toward the participant's deductible under this Plan for that calendar yeaz. 8ECTION III -LIFETIME MAXIMUM AND RESTORATION OF BENEFITB Each pazticipant is entitled to the services listed below when incurred while the Plan is in force and when necessary and consistent with the accident or sickness for which the participant is being treated. "uwwomew~w awa In1M 5chtlw. M eerehR/sq Pa{0 8 Florida Municipal Insurance Trust Medical Master Plan of Benefits Subject to the provisions of this Section for each participant under this Plan, the maximum liability of the Trust to such participant during the entire period such participant is covered hereunder shall be the amount specified in the Schedule of Benefits. (1) If, at any time, brnefite totaling at least $1,000 have become payable under this Plan to any participant, the maximum liability of the '!1 ust with respect to such participant during the subsequent period such participant is covered under this Plea may be restored to the amount specified in the Schedule of Benefits upon receipt and approval by the Trust of evidence of such participant's insurability. Such restoration will not be made during a calendar year in which expenses were incurred. Etidence of insurability must be furnished without expense to the Trust. (2) If, during any one calendaz year, more than $1,000 in benefits has become payable on behalf of a participant, said participant shall automatically be entitled to $1,000 in restored benefits commencing with the next succeeding year, regardless of whether the amount in the Schedule of Benefits has been reached. Items (1) and (2) of this Section do not pertain to the specific lifetime maximums of limited benefits. SECTION ZV -MAXIMUM EXPENSE TO PARTICIPANT8 When the covered experisea of a participant reach the amount specified in the Schedule of Benefits, subject to the coinsurance provisions, all further covered expenses for that calendar year will be paid at 100% of the actual reasonable fees, up to the Lifetime Maximum of the Plan. 8ECTION V - ELI4IBILITY AND ENROLLMENT rommencemeat of Goveraae -Subject to any waiting period set forth under this Plan and to any other condition of commencement expressed in this Plan, coverage hereunder shall commence ae follows: (1) In the event an employer had no group health plan covering its employees and dependents in effect immediately prior to the effective date of this Plan, all employees in the employ of such employer on the effective date of this Plan, and their eligible dependents, except a dependent that is totally disabled or a dependent that has been exposed to the HIV infection or a specific sickness or medical condition derived from such exposure, shall be eligible to participate in this Plan. Coverage shall commence as of the effective date of the Participation Agreement of the employer without proof of insurability provided the Treat receives a properly and accurately completed and executed enrollment form and any required medical statement application no later than 30 days following the effective date of the Participation Agreement. If ••ewe.nn.~w.wdex~uwr°nar.we..wtr/ul Pajs7 FlorldaManlatpallnsarancs•Tnat Medical Master Plan ot8eneflts application is not received on or before the expiration of 30 days following the effective date of the Participation Agreement of the employer, any application for coverage by an employee, or his eligible dependents, will be governed by the provisions set forth in Enrollment Paragraph (4). (2) bz the event an employee, or eligible dependents, were validly covered under a group health insurance plan issued to the employer and in effect immediately prior to the effective date of this Plan and -such plan is discontinued and replaced with this Plan, all such employees and eligible dependents actually covered. under such prior. plan .shall be eligible to participate in this Plan, without interruption of coverage and without proof of insurability, unless such employee or dependent is entitled to any extension of benefits in accordance with S. 627.667, F.S., under the teens of the prior plan, and provided the Trust receives a properly and accurately completed and executed enrollment form, and any required medical statement application, no later than 30 days following the effective date of the Participation Agreement of the employer. In the event such employee or dependent is entitled to an extension of benefits in accordance with S. 627.667, F.S.. under the -terms of the prior plan, such employee or participant shall be entitled to participate in this Plan without interruption of coverage and without proof of insurability provided the Trust receivga__~xx,,g~cy~~tely completed ,and executed enrollment form, and any required medical statement application, no later than 30 days. following the effective date of the Participation Agreement of the employer; however, the level of benefits under this Plan shalt be no more than the applicable level of ben~fita under this plan reduced by any benefits payable under the prior Plan. Upon request, the employer, employee and dependent shall provide the Trust such, information as is reasonably necessary,. including the prior plan, to coordinate the level of benefits payable under this Plan and the prior plan, for the Trust to verify the level of benefits provided under the prior plan, and to determine each employee and dependent who was .validly covered under the prior plan on the date of discontinuance of the prior plan. If application is not received on or before the expiration of 30 days following the effective date of the Participation Agreement of the employer, any application for coverage by an employee, or his eligible dependents, will be governed by the provisions set forth in Enrollment Paragraph (4). El~ibility -Employees and eligible dependents shall be eligible for coverage on or after the effective date of this Play if: (1) They fall within the classification set forth in the Employer's Participation Agreement; and (2) They have completed the period of continuous employment with the employer as set forth in such classification. An employee shall not be eligible as a dependent under the same employer group except when both spouses are eligible employees end desire dependent child(ren) coverage. In .that case, one employee may cover the spouse and children as dependents for health benefits and the spouse may be covered as a single employee for other employee coverage(s). Earollmeat -Employees and eligible dependents may enroll for coverage under the Plan by completing and submitting to the employer an accurately completed and executed enrollment form provided by the Trust, as specifi~.d below: ••udwex,..e..w.a w, e,. sareW..ee.n.eslt/eel Page a Florida Manidpal Insaraaa Tract Msdksl Master Plan of Benefits (1) Initial eNgibility riod -within 30 days of satisfaction of the Plan waiting period. (a) New employees, and their eligible dependents, except totally disabled dependents and dependents exposed to the HIV infection or a specific sialmeas or medical condition derived from such exposure, shall be eligible to participate in this Plan without proof of insurability, and shall commence on the first billing date following the eligibility requirements set forth above. If the enrollment form is not received on or before the expiration of the period set forth above, any application for coverage by a new employee or their dependents will be governed by the provisions set forth in Paragraph (4) of this section. (b) Except as otherwise provided in Commencement of Coverage Paragraph (2), in the event an employee or eligible dependent is hospital confined, totally disabled or otherwise disabled when coverage would otherwise begin, coverage will begin the billing date of the month following the employee or dependent's return to good health when able to perform the normal activities of a well person of the same age and sex. This subsection does not apply to a newborn child of an employee covered for dependent coverage at the time of birth. (c) In the event an employee's coverage terminates due to termination of employment and such employee returns to full-time employment within ninety (90) days, such employee's coverage may be reinstated without completing the period of continuous employment set forth in the Employer's Participation Agreement, provided an enrollment form is received by the Trust within thirty (30) days of the employee's return to employment. If the enrollment form is received more than thirty (30) days after the employee's return to employment, any application for coverage will be governed by the provisions set forth in Paragraph (4) of this section. (d) In the event an employee was covered under this Plan through another employer within thirty (30) days prior to beginning employment with this employer, such employee will not be required to complete the period of continuous employment set forth in the Employer's Participation Agreement, provided an enrollment form is received by the Trust within thirty (30) days of beginning employment with this employer. Required contributions must be paid at the new employer's rates from the prior billing date for reinstatement of continuous coverage. If the enrollment form is received more than thirty (30) days after the employee's return to employment, any application for coverage will be governed by the provisions set forth in Paragraph (4) of this section. (e) Pre-existing limitations will apply, as outlined in Section X. (2) Oven enrollment ~enod -within 30 days of the Plan's policy renewal anniversary. Eligible employees can enroll in the Plan or terminate coverage during the open enrollment period. Pre-existing limitations will apply, as outlined in Section X. If application is received 30 days or more following tPce _ Plan's policy renewal anniversary, any application for coverage by an employee or eligible dependents will be governed by the provisions set forth in Paragraph. (4) of this section. ••mo.n.arw~»wiwMn»s.n.ad.as.,ais~~/sa >., .M~?p~g~i~' Florida Municipal lnsuranco Trust Medical Mastsr Plan ofBenaftts (3) Special enrollment period -within 30 days of certain events or loss of coverage as outlined below: (a) An eligible employee and/or eligible dependent except a totally disabled dependent or a dependent exposed to the HIV infection qr a specific sickness-or medical condition derived from such exposure, was: m 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, sari m When offered coverage under this Plan at the time of initial eligibility stated, in writing, that coverage under another health plan was the reason for declining enrollment, sari ® Demonstrated that loss of coverage under an individual or group health benefit plan occurred within the past thirty (30) days as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, sad O Requests enrollment within thirty (30) days after the termination of coverage under another health benefit plan. (b) An individual why loses coverage as a result of termination for failure to pay premiums/prepayment fee on a timely basis, or the. diswntinuance of any contributions towazd the health coverage plan by the employer, or for cause does not have the right to special enrollment under this Plan. Voluntary termination of coverage does not constitute loss of eligibility of coverage. (c) A newly eligible dependent, except a totally disabled dependent or a dependent exposed to the HIV infection or a specific sickness or medical condition derived from such exposure, as a result of marriage, birth, adoption or placement for adoption, legal guardianship or court order, without proof of insurability provided the Trust has received an accurately completed and executed enrollment form, within thirty (30) days of the event. Eligible dependents may only be enrolled if the eligible dependent is a dependent of an employee who is already participating in the Plan. If the employee fails to apply within the thirty (30) day period, any application fer coverage will be governed by Paragraph (4) of this Section. ® In the event of marriage, the effective date of coverage shall be the first day of the month following receipt of notification by the Trust. ® In the event of a newborn, coverage will take effect on the date of birth and will continue for thirty (30) days. Coverage beyond this period requires the eruollment form as specified above. If application 'is'iidt received during this time period, the Trust reserves the right to charge an additional premium for coverage of such newborn from date of birth to the date of receipt of application or the end of the thirty (30) day period. ® In the event of an adoption of a newborn child, if a written application to adopt a newborn child has been entered into by the employee prior to the birth of the child, such child shall be subject to the conditions and entitled to the benefits and services provided in this Plan applicable to newborn children provided the child is ultimately adopted pursuant to Ch. 63, F.S. As a condition of coverage, the written agreement shall ••uwwomrraa.cw)owsa.ewore.anu(T/ss) -Page 10 Florida Municipal Insursn~»Tnut Madlcal Master Plan of Benefits accompany the employee's supplemental application for coverage for such child. As a condition of continued coverage, the employee shall immediately provide the Trust with a certified copy of the judgment of adoption upon its entry and the employee shall, upon request, provide to the Trust, under oath, such information as is reasonably necessary to keep the Trust apprised of the stage of the adoption proceeding, ® In the event of an adoption or placement for adoption (other than newborn), legal guazdianship or court order, the effective date of coverage shall be from the date of the child's placement in the employee's residence or date specified by court order. If application is not received within thirty (30) days of .the effective date, the Trust reserves the right to charge an additional premium for coverage of such child(ren) from the effective date to the date of receipt of application. As a condition of rnverage, the employee shall provide the Trust with a certified copy of the judgment of adoption, guardianship or court order. (d) Pre-existing limitations will apply, as outlined in Section X. (4) Those eligible employees who refuse coverage for themselves or thew eligible dependents under this Plan, those employees applying for coverage, including dependent coverage, under this Plan subsequent to the effective date of the Pazticipation Agreement of the employer, or those employees and dependents who do not satisfy the coverage provisions specified in Paragraphs (1), (2), and (3) of this Section may apply for coverage at a later date by medical statement application. Such employee, on behalf of himself/herself or his/her dependents, shall provide the Trust with a completed medical statement application and such applicants shall be subject to the applicable rules and regulations of the Trust. The Trust will review all medical statement applications and provide the eligible employee's employer with a notice of acceptance or notice of rejection. If accepted, the effective date of coverage for such applicant shall be the first day of the month following the receipt of notice of such acceptance. Pro-existing limitations will apply, as outlined in Section X. The employer shall submit such form and any required medical statement application, together-with any contribution due to the Trust, as a prerequisite to the coverage of such employee or dependent under this Plan. Certificates of creditable coverage, as specified in Section X, should be provided at the time an application for enrollment is made by the eligible employee and their eligible dependents. The employer does not act as an agent of the Trust in the enrollment and withdrawal of its employees and their eligible dependents. Notwithstanding, and in addition to, any other conditions expressed herein for coverage or payment of benefits and services, coverage for each employee and eligible dependents under this Plan shall commence no earlier than the first day of the month immediately following the date on which the Trust has actually received a properly and accurately completed and executed enrollment form and any required medical statement application and the contribution attributable to the pazticulaz employee and eligible dependents. ••utlw~a.rwwuarrrswe~reaw~ulr/fq Page 11 Florida Manicipal`InauranceTrust Madlcal Matter Plan of Boneflb BECTION VI -COVERED EXPEN8E$ If the employer and the participant have satisfied the terms and conditions provided in this Plan for coverage and for the payment of benefits and services, the participant is entitled to the benefits and services listed below when incurred while the Plan is in force and when medically necessary and consistent with the accident or siclmess for which the participant is being treated. The Trust will pay the reasonable fee for such benefits and services and, all such benefits and services, unless otherwise expressly provided herein, shall be subject to any calendar year deductible and/or coinsurance shown on the Schedule of Benefits. Pre-Admission Certification -All non-emergency hospital admissions must be: (1) certified seven (7) days prior to a planned admission; (2) certified within 48 hours or the fast working day after the admission. Failure to obtain certification will result in a 20% reduction of benefits paid. Pre-admission certification is not required for the birth of a child, provided the hospital or birthing center length of stay does not exceed: (1) 48 hours following.a vaginal delivery, or (2) 96 hours following a cesarean delivery. Inpatient Hospital ~srvices -The expense incurred for the following services will be paid as stated in the Schedule of Benefits (in excess of any deductible and/or coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the end of the calendaz year whichever first occurs. (1) Hospital room and board up to but not to exceed the average semi-private room rate. ** (2) Intensive care unit (including cardiac and neonatal care units) not to exceed three (3)** times the average semi-private room rate. (3) Progressive care unit up to but not to exceed one and one-half (1'/a) tunes file average semi-private room rate only if incurred immediately following.,a confinement in an intensive care unit. (4) Miscellaneous services and supplies provided such as operating and recovery room chazges, x-ray and other diagnostic procedures, laboratory testa, pathological services, medications and dressings. (5) Transfusion supplies and services including blood administration expenses but not including blood, blood plasma and/or blood derivatives unless otherwise specifically stated in this plan. (6) Anesthesia services, including supplies, equipment and physician's charges for regional, intravenous, inhalation, intraspinal and caudal anesthesia services when performed by a regular salaried hospital employee and when performed in connection with surgical, obstetrical**, electro-shock, or dental services** covered under this Plan. (7) Oxygen therapy, diathermy and physiotherapy. (8) Roentgenologic (x-ray) and cobalt bomb therapy when such therapy is in ••Unlm°uww~a~sbb°wiMSU~NaMwab(7/sq Paja 12 Florida Municipal Insurance Trust Medical Master Plan of Benefits connection with proven malignancies or for radium, radon or isotope therapy. (9) Obstetrical Care** -Maternity benefits will be provided to participants, subject to the same limitations and exclusions applied to as all other benefits provided under this Plan; provided, however, dependent children shall not be entitled to maternity benefits. Complications of pregnancy (excluding false labor, occasional spotting, prescribed rest, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions not constituting a nosologically distinct complication) are eligible for benefits on the same basis as any other illness. (10) Newborn Care -Eligible hospital services as provided herein for participants shall also be provided for a newborn dependent child of a participant from the moment of birth and shall include mentally diagnosed congenital defects, birth abnormalities or prematurity. A newborn infant of a dependent child is eligible and shall be covered so long as the dependent child is covered under the provisions of this Plan but not to exceed eighteen (18) months. Phvsicia^- Fl.*°t^~~ -The expenses incurred for the followin g physician services will be paid as stated in the Schedule of Benefits (in excess of any deductible and/or coinsurance) for reasonable fees up to the Lifetime Maximum of this Plan or to the end of the calendar year whichever first occurs. (1) Surgical Services -wherever performed, limited to operative procedures for the treatment of accident or siclmess. The surgical allowance includes post- operative treatment. (2) Surgical Assistant -provided the assistance is medically necessary, no intern, resident, or other staff Physician is available, and the condition of the patient and the type of eligible surgery performed require such assistance. (3) Consultations - which are medically necessary due to complications, complexity or different diagnosis. A consultation report must be part of the hospital medical records. (4) Anesthesia Administration -when rendered in connection with a covered surgical or obstetrical"• procedure __ _ (5) Obstetrical Care** - this expense will be considered incurred at the termination of the pregnancy. Dependent children shall not be entitled to maternity benefits. (6) Professional Component Expenses - of radiology, pathology and laboratory. ('~ Medically Necessary Hospital Visits -not including post-operative treatment. (8) Medically Necessary Care -rendered outside of the hospital. Routine physical examination expenses aze not covered, unless otherwise specifically stated in the Schedule of Benefits. (9) Dental Care and Treatment -rendered by a physician or dentist within ninety (90) days of an accident when, as the result of the accident, natural teeth have been damaged or fractured or a dislocated jaw requires setting. (10) Concurrent Care -combining medical surgical and obstetrical"* care whereby the Trust will pay for necessary eligible medical, surgical, or obstetrical** care and necessary eligible surgical obstetrical** care in addition to other eligible medical expense during a single hospital confinement. "Wlwrx wYS Maasaairs.ra«~My17/ssl Paga 13 Florida MunicipatlnsuranceTruct Medical Master Plso of Benaflb Florida Municipal Insuraaca Trust Madlcsl Master Plan of Benefits (11) Well Child Care -the reasonable fees chazged by a physician for physicals , examinations, developmental assessments, anticipatory guidance, ~ approval must be obtained by the Trust for prosthetics and other devices which exceeds $500 i t immunizations and laborato tests, in kee m with rY p g prevailing medical n coa . standards, which are not required for the treatment of illness or injury, for (5) Initial Eye Glasses or 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, aze payable subject to the following: (6) Hospital Charges -for emergenry room care or f i (a) A lifetime maximum of eighteen visits at the following age intervals; birth, or surg cal services performed in the outpatient department of a hos ital two months, four months, six months, nine months, twelve months p . , fifteen months, eighteen months, two years, throe yeaza, four years, five ~ (~) Altenlaiive Housing - in close proximity to a medical facility located in the yeazs, six years, eight years, ten yeaza; ~twel+ve years; fourteen years and state: sixteen years. (b) Benefits are limited to one visit payable to one physician for all service ~ (a) If the Trust 5nds a bone marrow transplant otherwise covered under the terms of this Platt 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 (bl Due to the special nature of the bone marrow transplant procedure it to the coinsurance, if applicable. , can be performed in no more than four medical facilities in the state the (12) Therapeutic Treatment - by a radiologist including radium, radon, isotope x- Participant does sot reside within 45 minutes driving time to the medical , ray and cobalt bomb therapy when in connection with proven malignancies. facility; (13) Newborn Care -when rendered by a physician to a newborn dependent child (c) Due to the special nature of the bone marrow transplant procedure, it is medical necessary for the participant to remai l of a participant, from. the momen(: of birth, for covered it{jury or sickness, includin assess g ~ ary care or treatment of medically diagnosed congenital n over a pro onged period of time in close proximity to the medical facili m which the tY ~ procedure was f defects, birth abnormalities, or prematurity. A newborn infant of a " "' ' " ' ' per ormed in order to closely monitor potential post-procedure complications directly related to the procedure depend erit c~i ild is eligible 2tid"ah all"be` covered so laag as the dependent child is covered but not to exceed eighteen (18) months. ; (d) The coats of the physician-directed inpatient hospital stay would far outweigh the coat of outpatient services combined with the alternative Other ffiedical Services -The expenses incurred for the following services will be housing. paid as stated in the Schedule of Benefits (in excess of any deductible and/or (e) The above findings and decisions to permit alternative housing, including coinsurance) for reasonable fees up to the Lifetime Maxunum of this Plan or to the those related to medical necessity, and the type, location, cost, length of end of the calendar year whichever first occurs. stay and nature of the alternative housing, shall be within the sole (1) Emergency Professional Ambulance Service - to the nearest hospital able to discretion of the Trust. The fact that a physician may prescribe, order, provide the care required for the patient. Transportation costa of a newborn to and from the neazest available facility appropriately staffed and e ui d recommend, or approve the alternative housing does not of itself make it medically necessary or make the expense an allowable expense ~ q ppe to treat the newborn's condition, when such transportation is certified by the . (~ Notwithstanding the other terms, conditions and limitations provided in attending physician as necessary to protect the health and safety of the this subsection, the Lifetime Maximum under this section is $10,000*'. newborn child shall be covered. The coverage of such transportation coats shall not exceed the reasonable fees, and in no event shall exceed the sum of $1 000.** Sunolemeatal Ancideat 8eneflt - Services under this Plan will be provided, as stated ~ in the Schedule of Benefits for each accident wh , (2) Prosthetic and Other Devices -initial (under this Plan) appliances, crutches, , en expenses are incurred, as the result of an accident for medical, surgical, and hospital care and treatment, within ninety (90) days subse uent t i braces, cardiac pacemakers, standard model wheelchair, or other mechanical appliances medically necessary for the coaection of conditions arising out of q o an acc dent not connected with employment and when such treatment has been prescribed by a physician. injuries or sickness, provided the equipment is prescribed by a physiciazi, and the equipment does not, in whole or in part, serve as a comfort or Expenses which arc incurred after the ninety (90) day period or after the maxunum for each accident has been h d i convenience item. Written approval must be obtained by the Trust for prosthetics and other devices which exceeds $500 in cost. The Treat shall reac e , w ll be paid as regular Plan benefits, subjeM to the deductible and/or coinsurance provisions of this Plan. have the right to buy or rent such appliances as they may elect. ~ 1)laaaoslie X-rav L~~~... d Y (3) Splints, Casts, Trusses. y an athologteai 8erviees -Services for outpatient hospital and physician charges for diagnostic x-ra l b ()Other Durable Medical 4 Equipment Rental -required for temporary therapeutic, y, a oratory and pathology required for the treatment of an illness shall be paid in accordance with the 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 ChironraoMo Servieos -The reasonable fees for chiropractic services shall be covered, subject to all Plan provisions, deductibles and coinsurance. ••uM...eu,.,,x..,dwMSrsdrma..eawmu(rissl Page 14 ••uN..soa~w,swra.aen~u~.wswwP/ul Page 15 Florida Munlclpat.lnaurancs Trust Msdlcal Master Plan ottieneflb Pre-Admia~oa Taborstory or Radioloav To_stia¢ -The expenses incurred for pre- admission laboratory or radiology testing will be payable at 100% of the reasonable fees, not subject to the calendaz yeaz deductible. The testing must be ordered by a physician, must not be duplicated by the hospital and must be performed no later than four (4) days prior to-an inpatient hospital confinement or an outpatient surgical procedure in order to be covered by this provision. All other expenses incurred for pre-admission laboratory or radiology testing shall be subject to the. calendar year deductible and coinsurance. Physical Theraivy 8erviees -Services of a Physical Therapist for physical therapy provided such services are provided oa an outpatient basis and further provided such services are limited to 40 visits, up to a $2,000"* per calendar yeaz maximum. ~coad 8usgical Opinions -Second surgical opinions may be required prior to surgery for the following surgical procedures: (1) Arthopiasty -plastic operation on a joint or the formation of an artificial joint when performed on the lonee or hip; (2} Arthroseopy -internal examination performed by the use of a scope, when performed on the lmee; _ (3) Cholecystectomy -removal of the gall bladder; ....... ... _r a, ,. -, (4J Coronary Bypass and Pacemaker Insertion; (5J Dilation and Gtitrettage (D&C); (6) Hemorrhoidedomy -removal of a mass of swollen varicose veins in the rectal mucous membrane; (7) Hysterectomy -removal of the uterus by excision; (8) Laminectomy or Laminotomy -removal of or incision into a disk; (9) Prostatectomy -excision of the prostrate gland; (10) Subcutaneous Mastectomy -excision of cyst, tumor, or lesion of the breast; (11) Submucous resection/rhinoplasty -surgical correction of deviated septum, plastic surgery on the nose; (12) Tonsillectomy/adenoidectomy - rcmoval of the tonsils and adenoids. Mental and Nervous Disorders** -The reasonable fees of the services of phyairaana, psychiatrists, licensed psychologists who hold a PsyD, and hospital for the treatment of mental and nervous disoadcas, as defined in the standard nomenclature of the American Psychiatric Association, limited to the maximum number of visits shown on the Schedule of Benefits, up to a $10,000 per calendar year maximum and a $25,000 lifetime maximum. Medicare Supplement Benefits - A participant over the age of 65 who retires from the employ of the employer while this Pian is in force is eligible for the Medicare Supplement coverage of this Plan. The supplement benefits are: (1) For initial hospital expenses for confinement as a hospital inpatient, the Plan will pay the Part A Medicare deductible. (2) For hospital inpatient expenses from the 61st day through 150th day of confinement per spell of illness, the Plan will pay the amount of the daily ••IhYwetlwUaal~tNMlMfcA~bb MMnMb17/tq Pagale Florida Muaklpal Insurenca Trutt Medical Master Man of Benefits Medicare deductible. (3) The Medicare Part B deductible is paid by the Plan at 100% per calendar year. (4) The Medicare Part B coinsurance is paid by the Plan for eligible reasonable fees incurred as determined by Medicare. (5) Prescription Medicines -When ordered by a physician, consistent with the treatment of a specific diagnosis, when dispensed by a licensed pharmacist, and when obtained through the mandatory prescription program provided in Section XVI of thin Plan. Vitamins, minerals, and over-the-counter medications are not eligible expenses. Expenses are subject to the individual calendaz year deductible and coinsurance as set forth in the former employer's Schedule of Benefits. (6) The Lifetime Maximum for all Medicare Supplement benefits is $1,000,000. Alcohol sad Drng De7,eadeacv Bea a* - As used in this Section "alcoholic" means a participant who chronically and habitually uses alcoholic beverages to the extent that it injures his/her health, substantially interferes with his/her social or economic functioning, or to the extent Lhat he/she has lost the power of self- control with respect to the use of such beverages. As used in this Section "drug dependent" means a participant who is dependent upon, or by reason of repeated use is in eminent danger of becoming dependent upon, any substance controlled under Ch. 893, F.S. The reasonable fees incurred as a result of the necessary care and treatment of an alcoholic or a drug dependent shall be wvered, subject to the following terms, conditions and limitations: (1)' Care and treatment must be provided by, provided under the supervision of, or prescribed by a state licensed physician or psychologist; (2) Care and treatment must be pursuant to a program accredited by the Joint Commission on Accreditation of Hospitals or approved by the State of Florida; (3) Benefits are limited to coverage stated on the Schedule of Benefits, with a $4,000 lifetime maximum; (4} Detoxification will not be considered a benefit under an outpatient program. Midaiferv sad 8 ~>. r • s Beael3t -The reasonable fees for midwifery services performed by a Certified Nurse Midwife or midwife and the reasonable fees incurred by a Birth Center for services and supplies furnished to a participant for prenatal care, delivery and postpartum care rendered within twenty-four (24) hours of delivery shall be covered, subject to all Plan provisions, deductibles, and coinsurance; provided, however, dependent children shall not be entitled to this benefit. vice Care Benoat - A participant will be eligible for hospice care benefits under this Plan if written approval is provided in advance by the Trust. The Trust will not provide written approval unless a written statement is submitted to the Trust by the Hospice Care Agency and the attending physician outlining: (1) and attesting that the patient is terminally ill, (2) and attesting that the patient has a life expectancy of six (6) months or less, ••ww«tr~w..arwtis.ta.aa°.n.~aap/tq Pege iT Florida Msnlclpai Insurancetruat Medical I[AastsrPlasof Banoflb (3) the range of charges for services that will or could be rendered. Hospice care benefits are for reasonable fees incurred for the palliation or management of terminal illness. Benefits shall be payable for the routine home care, and continuous home care subject to a Lifetime Maximum of $6,000**, for a maximum period of six (6) months. Hospice care will only be approved once for a participant. TM,I Benefit -The- teas; enable fees charged by a hospital, dentists, or physicians for the treatment of temporomandibulaz joint dysfunction are eligible for benefits up to a Lifetime Maatimum of $1,500**-for all services related to this coadidon. Only one $1,500.*~ lifetime benefit will be provided. Cardiac Rehabilitation Beaefitt -Service of a state licensed cardiac rehabilitation facility for cardiac rehabilitation on an outpatient basis up to a Lifetime Maximum of $2,000** provided such services are prescribed by a physician and provided under the direct supervision of a physician, A participant who is eligible for this benefit must meet thr following criteria: (1) Myocardial Infarction -post myocardial infazction patient may enter the program anytime, at the discretion. and referral from physician; (2) Post op Cardiovascular Surgery - a minimum of three weeks aorta- ooronary .bypasa.aurgery, or~diseretion and referral fromplsysician; (3) Adequate control of complications, i.e., angina, congestive heart failure or arrhythmias; (4) Pacemaker patients with any of the above diagnosis and/or decreasing functional capacity. Homo Heath C,*e Benefit -The reasonable fees, up to a maximum calendaz year benefit of $1,000, incurred for home health services performed by a home health agency resulting from an accident or siclutess to a participant while this Plan is in force shall be covered, subject to all Plan provisions; provided the services are performed pursuant to a written plan• of treatment prescribed by a physician that is approved in advance by the Trust. Skilled Nursit~ FaeLty Benefit -Services and supplies provided under the direction of a physician, provided the services are performed pursuant to a written plan of treatment prescribed by a physician that is approved is advance by the Trust. Maste tnv .Benefit -The reasonable fees for inpatient hospital and physician services associated with the aurgi`cal removal of aIl""or a" part of the breast if determined medically necessary by a licensed physician, prosthetic devices, and recoriatrtictive surgery incident to the maate~etomy; ahall'be covered, and subject to the following conditions and limitations: (1) Coverage for prosthetic devices and reconstructive surgery shall be liatited to the initial prosthetic device and initial reconstructive surgery incident to the mastectomy; (2) If the mastectomy reveals no evidence of malignancy, coverage for prosthetic devices and reconstructive surgery incident to the mastectomy is limited to an initial prosthetic device provided, and to medically necessary reconstructive surgery performed, within two (2) years of the date of the ••W+w.owwira~a~nu»sa~www.ae.o~neir/oe1 F~age 18 FlorWa Munldpalinauranoe Trust Medical Maebr plan of Fleneflb mastectomy. Mammoara+±+ Benefit -The reasonable fees for mammogram testing, breast cancer screening or diagnostic services, and health testing services utilizing radiology equipment (registered with the state's Department of Health and Rehabilitative Services) for breast cancer screening shall be covered, and according to these guidelines: (1) One baseline mammogram for women ages 35 to 40; (2) 9ne mammogram every 2 yeaza, or more frequently if prescribed by the participant's physician, for women ages 40 to 50; (3) One mammogram, every year for women 50 yeazs of age and over. Hoart. Heart-Luca. Hose Maaow Cornea Tissue B3daev aad Liver Trananlaat 8oaefib -The reasonable fees for inpatient hospital and physicians services associated with a heart, bone marrow, cornea tissue, kidney or liver transplant provided the participant meets objective criteria set forth by the medical industry for the tissue or organ transplant, the transplant procedure is performed in a facility duly licensed to facilitate the procedure by a physician duly credentialed to perform the transplant, the procedure is approved by the U.S. Food and Drug Administration, the transplant tissue or organ is donated to the participant and not purchased through an outside agent, and the transplanted tissue or organ originated from a human being and not from cadavers, animal laboratories, or other experimental sources. Due to the extensive nature of the services related to transplantations, a pre- determination must be obtained from the Trust. f3EC,TIOM VII -HOSPITAL BILL SELF-AUDIT The Trust will provide a payment to the participating employee in the amount of 50% of the savings (the total dollar difference between the original bill and the revised bill), not to exceed $1,000, The employee will receive a payment from the Trust for any errors that the employee identifies and the hospital corrects. The following steps must be taken by the participant before contacting the Trust: (1) Obtain a copy of the itemized bill before leaving the hospital or make arrangements for an itemized bill to be sent to you. (2) Review the hospital bill for overcharges or errors on the bill. (3) If the participant feels an error was made, the business office of the hospital must be contacted to review the possible error(s). (4) Request the business office of the hospital to satisfactorily explain the possible error(s) or issue a revised bill, which contain the credit(s) for the incorrect charge(s). (5) Send the revised bill to the Trust with a letter outlining your actions, the . 'w~uwenw.r.a.aawausarar.Na«Mwlr/aq Na8e19 FlorldaMunlclpaFlasurancsTmst MadlcalMsster Plan of Benefits amount of savings and your request for payment. SECTION VIII - EXCLU8ION8 AND LIMITATIONS Unless otherwise expressly covered in Section VI of the Plan, coverage under this Plan for participants is subject to the following exclusions ,and limitations for which no benefits shall be paid: (1) Services-or supplies "for beautifying br cosmetic purposes unless: (a) necessitated by an accidental injury while covered under this Plan and performed within six (6) months following the data of the accident, aad (b) required to restore a normal bodily function.. (2) Services,-or supplies provided by:any,enstodial:inatitution, rest hom~,,z~ursing home, sanitarium, health spa,. health resort,.. place of rest, institution or home for. the. aged,_ drug~_addicta,. oz alcoholics,. or.. a..,place for. the treatment of pulmonary tuberculosis or mental or nervous disorders. (3) Fees for routine physical ~YA*~++nations or periodic check-ups, except as otherwise speef~eally„Ptatec(,in this Plana .N..,...,.... w,,.. M , a ~:._~ (4) Any service or stYppIi'es to g' parficipanY ~iaspitalized for primarily rest, zest„cure.or,.pziutaril~G,for_nhseztlattonh. ~... ,w , (5) Services or supplies for injury or siclmess resulting from drug or alcohol abuse, or resulting from intoxication or consumption of drugs or alcohol. (6) Eye refractions, keratotomies, eyo glasses, hearing aids and examinations or the prescription or fitting thezeof, eye exercise, visual training or orthoptics. (7) 'travel expenses, whether or not travel is recommended by a physician. , (8) Hospital service- or.suppliea for..a participant who shall remain in a hospital after the attending physician advises that further hospital service is unnecessary. (9) Dentist, physician or hospital expenses for dental care and treatment including treatment or removal of teeth and immediately adjacent structures (ie. gingival) and any services for orthodontia, prosthodontia, periodontia and preparation for dentures unless; as'a result of an aeadent, natuial teeth have been damaged or a fracture or dislocated jaw requires setting, and then only if such dental treatment is rendered within ninety (90) days from the date of the accident. (10) Massage unless the massage is prescribed" by a-pliysieian, which prescription specifies the :comber of treatments and is performed under the direct supervision of a physician or by a massage therapist, and is approved in advance by the Trust. (11) Services or supplies forthe-primary purpose,.of.prauiding rehabilitation to a participant including, but not limited to, rehabilitative services related to alcohol and drug abuse or accident or siclmess arising therefrom, occupational therapy, speech therapy, and pain management training and educational programs. (12) Services or supplies for surgery for sexual reassignment or reconstruction, or ••uu...sw~w».»aeMa.saaa+.NSaaae,lr~ssl Pags20 Florida Municipal Insurance Trust Medical Master Plan of Benefits for reverse sterilization. (13) Infertility or medications prescribed to assist with fertility. (14) Contraceptive devices or appliances. (15) Services, supplies or medications prescribed for the treatment of sexual disorders. (16) Artificial insemination or in vitro-fertilization and/or any other form of artificial impregnation. (17) Elective abortions: (18) Services associated with autopsy or postmortem examination, including the autopsy. (19) Blood and blood plasma. (20) Services or supplies associated with the treatment of morbid obesity, including gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, jaw wiring, and services of a similar nature unless medically necessary. Services and supplies associated with weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature. (21) Private duty nursing by an RN or LPN whether in an inpatient hospital setting or skilled Wareing facility. (22) Biofeedback and other forms of self-care or self-help training and any related diagnostic testing, including exercise programs. (23) Foot care not related to the diagnosis or treatment of a condition. (24) Nicotine withdrawal programs, facilities and auppliea. (25) Transplants of any type except heart, heart-lung, bone marrow, cornea tissue, kidney, and liver transplants. (26) Services or auppliea which, in the opinion of the Trust, are experimental or not provided in accordance with accepted professional medical standards in the United States. (27) Services and supplies which, in the opinion of the Trust, are not medically necessary for the diagnosis or treatment of illness, injury or bodily malfunction. The fact that a physician may prescribe, order, recommend, or approve a service or supply does not of itself make it medically necessary or make the expense an allowable expense. (28) Professional medical or surgical services rendered by an individual who is related to the covered participant by blood or marriage. (29) Treatment, care, services or supplies which are obtained without cost to the participant. (30) Service or auppliea furnished to a participant or paid under any of the following plans or insurance coverages: (a) Any plan, program or insurance policy providing, benefits for hospital, medical 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 ~~uqM~.nrrwu.adu~susen.ew.as.n.n~rp/se- PaLs2i FlorldrMualclpal InaurancaTruot Medical Maatar Plan of Beneflb the State of Florida for the purpose of insuring a group of individuals; (b) Any plan, program or insurance policy, and/or PIP automobile insurance as required and defined in the Florida Statutes, which provides benefits or makes payments to or on behalf of a participant for hospital, medical and/or othr>r health care expenses; (c) any group contract issued to this Trust; (d) Any coverage under a plan or a law of any federal, state or local government or any political subdivision thereof, including but. not limited to, coverage under Medicare, and/or any other federal, state or local government-sponsored program or programs, unless otherwise provided by law; A participant shall have no right to benefits under this Plan if said participant elects to waive any entitlement to benefits provided under any plan described in this pazagraph. The participant shall provide, execute and deliver such information, instruments and papers, end do whatever else is necessary to secure the instruments and papers, and the Trust's rights under this paragraph. (31) Expenses that are covered under Parts A and B of Medicare, if the participant is not an active employee or the dependent of an active employee. (32) Treatment and/or drugs received in a veterans hospital or government facility due to a servicr connected disability. (33) Any service or supplies provided before coverage begins or after coverage terminates, for the group or for the participant, except to the extent and in the manner provided by Florida law and in the manner provided under Sections X, XIII, XIV and XV. (34) Personal comfort articles such as beauty and barber services, radio, and television. (35) All other services or supplies not furnished by a hospital for inpatient and/or outpatient treatment or specifically listed as covered expenses. (36) Discounts applied to total expenses by health care providers will not be used to satisfy deductibles or coinsurance under this Plan. ' (37) Any treatment for injury or siclmeas which a contributing cause was the participant's co:simission of, or attempt to commit, a felony, or the participant being engaged in any illegal act. (38) Preexisting conditions, except to the extent end in the manner provided in Section X. (39) Services or supplies for any occupational condition, ailment or injury arising out of or in the course of employment for wage or profit or any other endeavor for potential profit or gain, or services which are furnished to a participant under the laws of the United States or any state or political subdivision thereof, for which the participant shall have no right under this Plan,-even though the participant elects to waive that right to such benefits or service. (40) Services or supplies for injury or illness resulting from suicide or attempted suicide, self-inflicted injury or self-induced illness, whether sane or insane. This includes participation in and/or incitement of an altercation. ••unw~.a~..mew~nn»saww.ds.wiu(r~aq Page2Z Florida Munklpal Insuranee Trwt Medkal Master Plan of Beneflb (41) Services or supplies for injuries sustained or siclatesa contracted while in any military force of any country while such country is engaged in war or hostilities (whether or not declared), or while performing police duty as a member of any military organization. (42) Services or supplies for injury or illness that results from deliberately and voluntarily undertaking activities that subject the participant to unnecessary exposure to danger or unnecessary exposure to obvious risk of injury. This exclusion shall not apply to services or supplies for injury or illness resulting from the participant's participation in sponsored sporting events or traditional recreational activities. (43) Services or supplies for complications, which result from or arise out of the provision of services or supplies that are excluded under this Section. (44) Fees is excess of the percentage specified in the Schedule of Benefits, or in excess of rea: onable fees. Benefits payable under this Plan will be limited to services provided and expenses incurred within the continental United States. Any expenses incurred by a participant outside the continental United States will be subject to approval by the Treat. SECTION IR -COORDINATION OF BENEFITS The purpose of health care coverage is to help meet actual expenses. In line with that purpose, this Plan contains anon-profit provision coordinating it with other plans, including group plena under which a participant is covered, so that the total benefits available will not exceed 100% of the allowable expenses. Z~y Coverage - A plan without a coordinating provision is always the primary plan. If all Plana have this provision: (1) the plan covering the person as an employee rather than as a dependent is PranarY; (2) the plan covering the person as an active employee or as a dependent of an active employee rather than Medicare is primary; (3) if a child is covered under both parents' plena, the plan for the parent with the earliest birthdate in the calendar year is primary; (4) if a dependent child is covered under both parents' plans, and both parents have the same birthday, the plan which has covered the parent for a longer period of time is primary; (5) if a dependent child is covered under both parents' plena, and the parents are divorced or separated, the primary plan will be determined in the following order: ' First, the plan of the parent with custody of the child; ' Second, the plan of the spouse of the parent with the custody of the child; end ' Third, the plan of the parent not having custody of the child; •~~s~u..+r~r,aMSenaua.ra.~.mlrisq Pags23 FlorWa Munklpat InwrancaTrust Msdical Master Plan of Beneflts unless the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child in which case the plan covering such parent is primary. A copy of the court decree must be furnished to the Trust; (6) The Plan covering an employee, or the employee's dependents, rather than a retiree, or then :~tiree's dependents, is primary; (7) The Plan covering a person as an employee who has not retired, or the employee's dependents, rather than the plan covering a person, or the person's dependents, as a retiree, is primary; (8) The Plan covering a person as an employee, or the employee's dependents, rather than a plan covering the person, or the person's dependents, under COBRA, shall be primary. If none of the above rules apply, the plan that covered an employee or dependent for a longer period of time is primary. Secoadary Cover~f -Services and benefits under this Plan will be coordinated with, and this Plan is hereby deemed secondary to plans providing coverage for services, supplies or benefits furnished to a participant or paid under any of the following plans of insurance coverage: (1) any plan, program or insurance policy providing benefits for hospital, medical and/or other health Bare expansesunder a group master policy including, but not limited to, policies issued to any health maintenance organization or any entity to which such policies may legally be issued in the State of Florida. for the purpose of insuring a group of individuals; (2) say plan, program or insurance policy and/or PIP automobile insurance as required and defined in the Florida Statutes, which provides benefits or makes payments to or on behalf of a participant for hospital, medical and/or other health care expenses; I~' (3) any group contract issued to this Trust; ",CI, (4) any coverage under a plan or law of any federal, state or local government or any political subdivision thereof, including but not limited to, cove;age under ,~ Medicare and/or any other federal state or local government-sponsored ~ program or programs, unless otherwise provided by law. (5) A participant sh^+ll have no right to benefits under this Plan if said participant iI elects to waive any entitlement to benefits provided under any plan described ~i,j~ in this paragraph. The participant shall provide, execute and deliver such information, instruments and papers, and do whatever else is necessary to Ij secure the instruments and papers, and the Trust's rights under this i pazagraph. ~i l ~i i SECTION X -PRE-EXISTING CONDITIONS LIMITATIONS ' There is no coverage under this Plan for services or supplies to treat apre-existing ~ condition or conditions arising from apre-existing condition, until the participant has been continuously covered under this Plan: j (1) fora 12 month period beginning on the date of hire for employees and their I ••UNwNhrMwwbd In1MSoMOM N Y~nAbIT/fB1 P~ ~ Florida Municipal Insurance Trust Medical Master Plan of Bensftb ~~`-'"~~ dependents who enroll in the Plan during the initial enrollment period, and (2) fora 12 month period beginning on the effective date for employees and their dependents who enroll in the Plan during the open enrollment period and the special enrollment period. All participants enrolled subsequent to the effective date of this Plan will be subject to this pre-existing condition limitation, except newborn or adopted dependents that are properly enrolled in accordance with this plan, Credit will be given for the time an eligible participant was covered under previous coverage, if the previous coverage was similaz to or exceeded the coverage provided under this Plan and the previous coverage was continuous to a date not more than 62 days prior to the pazticipant's effective date of coverage under this Plan, exclusive of any waiting period under this Plan. The eligible pazticipant may prove periods of prior health coverage by providing a certificate of creditable coverage, which includes periods of coverage and benefit coverage levels. No pre-existing limitation will apply for an eligible participant presenting a certificate of creditable coverage indicating continuous coverage similar to or exceeding the coverage provided under this Plan, if the previous coverage was more than 12 months with no more than a 62 break in coverage prior to the participant's effective date of coverage under this Plan, exclusive of any waiting period under this Plan. 8ECTION XI -TIME OF PAYMENT, GRACE PERIOD All contributions are due and payable on the first day of each month for which coverage under this Plan is provided. If the employer fails to pay the contributions to the Trust within twenty (20) days after they become due and payable, the Pian is automatically terminated effective the first day of the month in which such contributions were due and payable; no participant shall thereafter be entitled to any further benefits hereunder. In the event this Plan terminates for any reason, the employer shall be liable for all contributions due and unpaid as of the date of termination in the event that claims were paid after the contributions became due and payable. The Trust must give an employer forty-five (45) days written notice of any change in the monthly rate of contribution or any changes in this Plan's terms or benefits. ~' 8ECTION XII -CONDITIONS FOR RENDERING 8ERVICE The participant shall present proper identification issued by the Trust when applying for hospital, physician, pharmacy or other medical services covered under this Plan. The Plan does not confer upon the Trust or any hospital any rights to select a physician for the participant. The participant shall be at liberty to elect his or her Y ••urwNewx.wwtis„sauad.NS..se,ir/ssl Page 25 FlorldsMunlclpallnsurance.Trust Medlaal Master Plan of Benoflts physician, provided such physician is acceptable for practice in the hospital to which the participant is admitted. Nothing contained herein shall interfere with the ordinary relationship between the participant and the physician selected by the participant. Some employers may elect to make special arrangements with specific providers 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 will be paid on such terms and conditions as are agreed to in writing by the employer and the Trust. The Trust does not undertake to furnish any services, but merely to pay for services to the participant to the extent herein specified. The Trust shall not, in any event, be liable for any negligence, misfeasance, nonfeasance, malfeasance, malpractice or any act of commission or omission on Lhe part of any physician, hospital or other service provider or the agent or employee of any physician, hospital or other service provider. SECTION XIII -EMPLOYER'S TERMINATION AND RENEWAL Except as provided in Section XI, this Plan may be terminated by either party hereto by giving not less than forty-five (45) days written notice of termination to the other. This Plan shall~continue in force from-month to month unless terminated pursuant to the foregoing provision. Except as hereafter provided, coverage for all employees and their dependents covered under this Plan shall automatically terminate immediately on the earliest of the following dates: (1) On the date coverage under this group plan with an employer is terminated. (2) On the expiration date as provided in Section XI, if the employer fails to make the required contributions. All claims must be submitted no later than ninety (90) days after the data of termination of the policy in order to be eligible for payment. SECTION 7i:IV - PARTICIPANT'8 TERMINATION OF COVERAQrE Unless a participant qualifies for and elects continuation of coverage pursuant to and in the manner provided in Section XV of the Plan: (1) Coverage for a:~y participant shall terminate automatically at the end of the month for which payment of the contributions specified herein shall have been made by the employer for such participant. In the event the employer notifies the Trust that the coverage of such participant under this Plan is to be terminated. (2) Coverage of the spouse of an employee shall automatically cease upon a legal separation of the spouse and employee or termination of the marriage between the spouse and employee. (3) Coverage of the spouse and dependents of an employee shall automatically cease upon the death of the employee. (4) Coverage of a dependent child of an employee shall automatically cease as ••u~....n^.wwe,ere.s~nw.sa.e.astr/eq Paee28 Florida Munlclpal IasurancsTrust Medical Master Plan of Benefits provided under Section I -Dependent. (5) Coverage of the employee, and spouse and dependents of an employee shall automatically cease upon the employee becoming entitled to the benefits provided under the Title XVIII of the Social Security Act (Medicaze). (6) Subject to the provisions of Paragraphs (1) and (2) of Section III, the coverage of any participant shall terminate automatically when the maximum benefits for which such participant is eligible have been paid. Coverage for any remaining family participants shall, unless otherwise terminated in accordance with provisions hereof, continue so long as payment of required contributions is timely made. A certificate of creditable coverage will be issued to all participants whose coverage terminates. The certificate will be sent by First Class Mail to the participant's last known address. In addition, the Trusi shall issue a certificate of credible coverage to a participant upon request, for up to 24 months following the end of the participant's coverage under this Plan. ~vnvararon rnvra6¢e OII TBrmrnat30II O! $lf bJ (1) A participant whose coverage under this Plan is terminated for any reason and who has been validly and continuously covered under this Plan for at least three (3) months immediately prior to such termination shall be entitled to purchase a converted policy. The participant must apply to the Trust for the converted policy in writing and must pay the 5rst premium attributable to the converted policy within thirty-one (31) days of the date of termination. The premium for such policy will be determined with premium rates applicable to the age and class of risk of each participant that is to be covered under the policy and to the type and amount of coverage provided, however, in no event shall such premium exceed 200 percent of the standard risk rate as established by the Florida Comprehensive Health Association, adjusted for differences in benefit levels and structure between the converted policy and the policy offered by the Florida Comprehensive Health Association. The converted policy will be issued without evidence of insurability and will be effective on the day following the termination of coverage under this Plan. (2) A participant is not entitled to a converted policy: (a) If termination is the result of the participant or employer's failure to timely pay a required contribution. (b) If any discontinued coverage under this Plen is replaced by similar group coverage within thirty-one (31) days of the date of termination of this Plan. (c) If the participant is covered or eligible to be covered by Medicare. (d) If the person is covered or eligible to be covered under a group policy or similar benefits are available to the participant under state or federal law, and the coverage or benefits, when combined with the benefits of the converted policy, will result in the participant's overinsurance. (3) .The., tettna .and coverage conditions in and benefits provider under the converted policy will be designed to comply with S. 627.6675, F.S., and the terms of S. 6?.7.6675, F.S., shall prevail to the extent of any conflict with the terms. of this Plan. `: i~(4)'. 77ie'converted policy may be issued by an authorized insurer seleMed by the Trust to provide conversion coverage. ".,`;i, t~r4Ar+aW.san.e~w.rew^eutr/nl Pa`e27 ,- _..a. ..F Florida Municipal Insurance Trust Msdiwl Master Plan of Benefits SECTION XV -CONTINUATION OF COVERACi~E -COBRA The Plan provides an election for continuation of coverage to qualified beneficiaries who would otherwise lose coverage under the Ptan as a result of a qualifying event. A qualified beneficzaru means the covered spouse or dependent child of a covered employee who is a participant in the Plan on the day before the qualifying event. Irt the case of termination, the term also includes the covered employee. One exception to this rule is when a child is bom to (or placed for adoption with) an employee during the COBRA continuation period. These childrett_will.receive-all rights.of a qualified beneficiary throughout the COBRA continuation period. A ali ing event means the occurrence of any of the following events, which would result in the loss of coverage to: (1) Employee: (a) Termination of employment for any reason other than gross misconduct. (b) Reduction of work hours. (2) Spouse: (a) Termination. of employee's employment. (b) Reduction of employee's work hours. (c) Death of employee. (d) Divorce or legal separation from employee. (e) Employee becomes enrolled in Medicare. (f) A covered dependent child ceases to be a dependent under the Plan. (3) Dopeadant: (a) Termination of employee's employment. (b) Reduction of employee's work hours. (c) Death of employee. (d) Divorce or legal aepazation from employee. (e) Employee becomes enrolled in Medicare. (fj Dependent child ceases to be an eligible dependent ae defined by the Plan. Continuation of coverage is conditioned upon satisfaction of the following notice requirements. The notice requirement relating to election coverage by qualified beneficiaries is as follows: (1) In the event of an employee's death, termination of employment or Medicare eligibility, the employer shall notify the Trust within thirty (30) days of such event. Upon receipt of notice, the Trust shall, within fourteen (14) days, notify the qualified beneficiary of his/her right to elect continuation coverage under the Plan. (2) In the event of divorce, legal separation or a dependent child ceasing to qualify as a dependent under the Plan, the employee or the qualified beneficiary is required to notify the Trust within-sixty (60) days of such qualifying event. Upon receipt of notice, the Trust shall, within fourteen (14) days, notify the qualified beneficiary of his/her right to elect continuation of coverage under the Plan. °u~watiMwa.raew NUrsae.aw.rs.Mes (r~sq Pate 28 Florida Municipal Insurance Trust Msdkal Master Plan of Benefits (3) Notice hereunder to employees or qualified beneficiaries shall be by First Class Mail to their last known address; notice to the Trust shall be by First Class Mail to the Boazd of Trustees of the Florida Municipal Insurance Trust. A qualified beneficiary's election of continuation of coverage must be made within sixty (60) days following notice to the qualified beneficiary. If the qualifying event is termination, the covered employee's election of continuation coverage shall be deemed to include an election of continuation of coverage on behalf of any other qualified beneficiary who would lose coverage under the Plan by reason of the termination. [f any other qualifying event occurs, the election of continuation of coverage by the spouse shall be deemed to include an election of continuation coverage on behalf of any other qualified beneficiary who would lose coverage under the Plan by reason of the qualifying event. ' The cost of coverage to the qualified beneficiary shall be 102% of the cost of providing coverage for such period to a similarly situated participant under the Plan to whom a qualifying event has not occurred. In the event the qualifying event entitling the qualified beneficiary to continuation of coverage is the covered beneficiary's disability as defined by the Social Security Act, the cost of coverage to the qualified beneficiary for any month after the 18th month of wntinuation coverage following the date of termination shall be 150% of the cost of providing coverage for such period to a similarly situated participant under the Plan to whom the qualifying event has not occurred. The coat of coverage shall be paid directly to the employer in monthly installments. In the event of a covered employee's termination, the period of continuation of coverage is: (1) Up to eighteen (18) months from the date of said termination for such employee and the employee's qualified beneficiaries. (2) Up to thirty-six (36) months from the date of employee's death, divorce, or legal separation for such employee's covered surviving spouse, divorced spouse, legally separated spouse and such employee's covered dependents. (3) Up to thirty-six (36) months from the date a covered dependent child ceases to be covered as an eligible dependent under the Plan. (4) Up to thirty-six (36) months from the date the covered employee becomes entitled to Medicare benefits for the employee's covered spouse and dependents. (5) Up to twenty-nine (29) months from the date of such termination for such employee and such employee's qualified beneficiaries, if it is determined, under Title II or XVI of the Social Security Act, the covered employee was disabled on the date of termination. The employee must notify the Trust of said determination within sixty (60) days of said determination and within eighteen (1B) months of the date of termination. In the event another qualifying event occurs during the eighteen (18) months following the date of the employee's termination, the period of continuation of coverage is up to thirty-six (36) months from the date of termination for such employee and his qualified beneficiaries. A qualified beneficiary's continuation of coverage shall cease on the earliest of the ••uwrw~rr.waabawsen.iwNS.Mwlrisel Pags28 Florida Municipal lnsurapc>l Tnlst Medical Master Plan of Benefits following; (1) The maximum coverage period date allowed for the qualifying event; (2) The date on which the employer ceases to provide any group health plan to all employees; (3) As provided in Section XI, if the qualified beneficiary fails to pay contributions within thirty (30) days after they become due; (4) The date the qualified beneficiary becomes covered under another group healtks plan. (as aa.employee. or otherwise) with, similar coverage, -which does not contain any exclusions or limitations for pre-existing conditions; (5) The date the qualified beneficiary becomes entitled to Medicare benefits; (6) If the coverage period is twenty-nine (29) months and the employee ceases to be totally disabled, on the first day of the month within the coverage period that begins more than eighteen (18) months after the date of termination and is more than thirty (30) days after the date on which the employee ceased to be totally disabled under Title II or XVI of the' Social Security Act. However, in no event shall. the coverage period extend beyond twenty-Trine (29) months from the date of termination. Notwithstanding the above, in no event shall sand. coverage extend beyond the twenty-nine {29) month coverage period. A certificate of creditable coverage will be issued at the end of the continuation of coverage period: The certificate wtl be sent. by Fsst Class-Mail to the participant's last known address. In addition, the Trust shall issue a certificate of credible coverage to a participant upon request, for up to 24 months following the end of the participant's coverage under this Plan. If COBRA is elected and the eighteen (18) or thirty-six (36i months maximum time frame is exhausted, the qualified beneficiary may be eligible for coverage under an individual plan (through an insurer of their choice) on a guaranteed issue basis without any pre-existing condition limitations. In the event the Plan offers a conversion privilege, the qualified beneficiary shall be entitled to said conversion privilege provided the qualified beneficiary applies for such conversion plan during the last 180 days of the period of continuation coverage. Coordination of Benefits with other plans for COBRA recipients will follow current National Association of Insurance Commissioners (NAIC) recommendations. SECTION XVI -PRESCRIPTION DRUGS Coverage is provided for prescription medications prescribed by a physician which are intended for use outside a hospital, skilled nursing facility or treatment facility. $enefits will be paid at the coverage level shown on the Schedule of Benefits. Presenting your prescription identification card each time you request a prescribed medication will ensure that the provider knows that you are part of the plan. A generic prescription drug will be provided unless the prescribing physician specifies a brand name drug. In addition to the applicable exclusions specified in Section VIII, no coverage is provided for: ••um.coma.iw.uae~ns»sa»ew•ra•n.aslr/sel Paga30 Fb-Ida Municipal Insurance Trust Medleal Mastsr Plan of Benefits (1) Drugs related to a course of treatment excluded, or a condition limited under the Plan. (2) Injectable products and syringes (other than insulin and insulin syringes). (3) Prescription Vitamins. (4) Nicorette Gum, Nicotine patches such as Habitrol, ProStep, Nicoderm. (5) Viagra and other similar virility enhancement drugs. (6) Rogaine and other similar medications for baldness. (7) Anorexics (appetite depressants such as "diet pills"). (8) Diabetic Teat Strips and glucometora. (9) Over the Counter medications and supplies. (10) Over the Counter Vitamins.., (11) Drug prescriptions of thirty (30) or more days' duration. A Prescription Mail Program is available to meet the maintenance drug prescription tteeds of a participant. Only maintenance drug prescriptions of over thirty (30) days and less than ninety-one (91) days' duration are eligible for this program. No coverage is provided for the exclusions specified in Section VIII, and Items (1) through (10) listed above. SECTION XVII - GENERAL PROVI8ION8 The Trust will issue to the employer for delivery to each participating employee covered hereunder, a Schedule of Benefits, a copy of this Plan and appropriate identification cards, which the employee or eligible covered dependents can present to a hospital, physician or other service provider in claiming benefits due under this Plan. It shall be the employer's responsibility to disseminate to the eligible employee the Schedule of Benefits, a copy of this Plan end the appropriate identification cards. The employee's benefits are non-assignable prior to a claim. If any amendment to this Plan shall materially affect any benefits, the amendment, a new Schedule of Benefits and an updated copy of this Plan shall be delivered to the participating employer to be distributed to employees. The Trustees shall provide benefits that are designed to 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 modification or discontinuance shall be mailed to the employer's last known address at least forty-five (45) days prior to the effective date of such modification or discontinuance. All statements made by employers or the employees of such employers shall be deemed representations and not warranties and no statement made for the purpose of effecting coverage shall void such coverage or reduce benefits unless contained in a written instrument signed by the employer or employee of such employer, a copy of which has been furnished to such employer or employee as the case may be. No reduction in benefits shall be made by reason of change in the occupation of any employee while in the employ of the employer or by reason of the employee's doing any act or thing pertaining to any other occupation, except as otherwise provided in Section VI. No representative has authority to change this Plan or waive any of its provisions. No !_ ••mYowanrwmwlnar s•M1WdeaiMlbl~/N) Page 31 FlorlQa MunlelpatinauranceTtust Madlcal Mastar Plan of BanaHq change in this Plan shall be valid unless approved by the Board of Trustees. Written proof of claim for services shall be furnished to the Trust within 365 days after the date of such services. Benefits provided in this Plan will be payable to the hospital, physician or other service provider rendering service under this Plan or to the participant upon receipt, by the Trust, of paid bills in acceptable form. No action at law or in equity shall be'brought to recover under this Plaa prior to-the expiration of sixty (60) days written notice to the Trust. No such action shall be brought after the expiration of the specified statute of limitations on such action. Such notice to the Trust shall be sufficient if given to: The Florida Municipal Insurance Treat Attention: Health Department 135 E. Colonial Drive Orlando, Florida 32803 An employee applying for coverage under this Plan for himself/herself or eligible dependents and the participant and/or each dependent of the participant agrees that, as a conditiorrof payment-of~bonefits,services and.snpplies, any hospital, physician or other service provider that has made or may hereafter make a diagnosis, render service,. attendan~e.,tlar ttute_,.~t~of.of to a~articipant, mad furnish and is authorized to furnish to the Trust at any time upon its request, a report containing all information and records or copies of records pertaining to diagnosis, attendance, service or treatment. The applicant or participant and/or each dependent of :the applicant or participant agrees as a condition of payment of benefits or services, to execute such medical authorization as may be required by the Trust. The Trust shall not be responsible for the payment of any expense for services or supplies not covered by this Plan or any amounts in excess of the maximum benefits allowed by this Plan. Eligible new participants may be added to the Plan in accordance with the terms and conditions of the Plan. No otherwise eligible employee or dependent of a participating employer. shall be refused coverage or be charged an unfairly discriminatory rate for participation solely because such employee or dependent is mentally or physically handicapped;. provided, however, nothing in this Plan shall be construed to require the Trust to provide coverage against a handicap which the applicant sustained on or before the applicant's effective date of coverage, In the event coverage under this Plan is conditioned upon a certain event or condition, or conditioned upon the continuation of a certain event or condition, the burden is on the participant to establish the existence of such event or condition or the continuation of such event or condition. To the extent of any conflict, the express words and language in this Plan will prevail over any oral or written communications to or by the Trust concerning the terms and conditions expressed in this Plan and such communications. are hereby deemed to be modified to reflect the terms and conditions in this Plan in the event such conflict ••UYwcaoanMw~6lM iahtlMorarMlb(7/») Page32 Fbrlda Municipal Insurance Trust Medkal Maatsr Plan of Benefits arises. The burden is on the applicant or participant to make complete and accurate representations to the Trust concerning questions of eligibility, coverage and services or benefits under this Plan. SECTION XVIII -PAYMENT OF BENEFITS. A88I(iNMENT Benefits provided under this Plan for a specified injury or sickness may be paid to the participant or to the service provider who has provided or paid for services or supplies for which such benefits are payable. Such benefits may be assigned by the participant to such provider and will be paid according to the participant's designation on the claim form, but only to the extent such provider's interest shall appear; otherwise this Plan and such benefits are non-assignable. If benefits are paid prior to the receipt and acceptance by the Trust of any assignment of such benefits, the assignment shall be null and void and unenforceable against the Trust. In the event an employee or dependent dies, or is physically, mentally or otherwise incapable of making payment due to a service provider, Plan benefits may be paid directly to the service provider or to any person or institution appearing to assume responsibility for the expense, aad such payment shall discharge the Trust's obligation for such expense. 8ECTION XIX - QrRIEVANCE PROCEDURE There are situations when participants have questions about their coverage or are dissatisfied with Plan services. Such inquiries and complaints will be handled in a timely manner. In the event that a claim is denied and the participant disagrees with the denial, a re- determination may be requested in writing detailing the reasons for the disagreement. This request must be received within sixty (60) days of the initial claim denial. The Plan will respond with a written decision, within sixty (60) days from receipt of the request. BECTION XX - 8UBROOATION In the event of any payment for benefits, services or supplies provided to a participant under the Plan, the Trust, to the extent of such payment, shall be subrogated to all rights of recovery such participant has against any person or organization, and the participant, as a condition precedent to the payment for any benefits, services or supplies otherwise payable under this Plen, shall execute and deliver such instruments and papers as may be required and do whatever else is necessary to °- ~- secure such rights to the Trust and shall otherwise assist end cooperate with the Trust as may be necessary in its efforts to recover such payment. '~~.mw.(waewrm.aoewwNernMUlU»- Page83 Florida MunicipafinaurancaTnist Modlcal Master Plan otfieneflts 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 l35 E. Colonial Drive Orl`ando,'Fitrrida 32801 Nolen ••u~w«an.nN..wueraNSa~.a~..re«rnsa/'a1 Pe~34